Intuniv for ADHD: Understanding Tenex, Guanfacine and Alpha 2

by Dr Charles Parker on July 20, 2009 · 259 comments

3733972075 bd7d39ff90 m2 Intuniv for ADHD: Understanding Tenex, Guanfacine and Alpha 2

ADHD Medications: The Science of Mind Evolves

Good Morning! – to a new ADHD world with more treatment options coming this fall. I just replied to a previous comment regarding the use of Tenex, guanfacine, [previously identified as helpful for tic disorder], and will send out this brief note with an interesting reference worth reading.

Short note, new vocabulary, take a moment sometime this week to chase down these links – they will likely soon become part of your everyday thinking in ADHD treatment.

Let’s make this simple, – er, let’s try to make the basic pharmacology a bit more understandable. Best to start with the basics, and this article in Science Daily breaks down an interview with a neurophysiologist at Yale, Amy Arnsten PhD, who has been looking at alpha 2 adrenoreceptors for several years now.

I’ve heard Amy present this interesting material, and know it needs translation, so I will simplify this brief note for you -

The real value to this new formulation:

  1. New brain information takes us beyond simply thinking about the synapse – into brain networks, systems and our new friend: ion channels
  2. This medication is not a stimulant
  3. More interesting information about brain function arises from evidence – and appears to offer significant possibilities for ADHD treatment.

New Post
Heads up readers: Posted an even more precise post on Intuniv for ADHD: Dosing Details – Do pop over there if you find this topic of interest. – And do take a moment to review all the Intuniv posts here at CorePsych Blog.  Several years have passed since this first post, and more understanding, more clinical experience provides more insight.

Remember this main ADHD Medication point: Intuniv is great, works well often, but isn’t for everybody. What Intuniv does do: on the one hand solves some previously unsolvable ADHD medication challenges – but on the other hand encourages even deeper insights for those ADHD presentations that fail to respond to any of these medications.

cp

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Intuniv for ADHD: Understanding Tenex, Guanfacine and Alpha 2

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Tagged as: ADD and ADHD, ADD/ADHD medications, ADHD Medications, ADHD treatment, Adult attention deficit hyperactivity disorder, alpha 2 adrenoreceptors, alpha 2 agonist, attention deficit hyperactivity disorder controversies, Attention-deficit hyperactivity disorder, brain, Child and Adolescent, childhood psychiatric disorders, educational psychology, Guanfacine, Mental health, Neurological Disorders, Stimulant, Stimulants, Tenex, tenex adhd, Tic disorder, Yale University

Newer Comments →
  • Rebecca Keller

    My son has been on Intuniv about a month and we would not consider it a success. He is highly impulsive at school and it does not help his attention at all. He is wiped out contantly. 2mg and he is in bed right after school all the way through dinner and beyond. Gonna try to back down to 1 1/2mg but probably will pull the plug. Was hopeful at first but it really is no help at all. The only positive side is that he is in a good mood compared to his experience with other ADHD meds. He previously was on Concerta and he was very aggitated.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Rebecca,
      Intuniv, as mentioned in another reply is not the silver bullet for complicated cases, as more than one neurotransmitter system is likely in play… and the most important, overlooked issue in complicated, poorly responsive situations is the issue of immune dysfunction and the cytokine question – take a look at this webinar which may come close to the issue for you.
      cp

  • Cindy

    Hello Dr. Parker,
    My 10 year old son is on Vyvanse and is starting Intuniv this weekend. I believe I’ve read instructions here for how to drop down the dosage on Vyvanse while gradually increasing the Intuniv. Our pediatrician is well-versed on the latter, but I got no info on reducing Vyvanse. In any case, I’m having a lot of trouble finding the info here using the search engine, because so much seems to be buried in the comments section. I hope that a) you can help me, and b) this feedback is helpful to you. I refer friends to your site frequently, btw!
    Thanks so much.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Cindy,
      Vyvanse titration strategies are easily found by using the *Search* box on the blog here – just type in Vyvanse and your will be busy for awhile! If you want a quick link to a site loaded with titration strategies try this one: http://www.squidoo.com/vyvnase and don’t forget to download my instructive and easy White Paper on Predictable Solutions for ADHD Medications here.
      Thanks, cp

  • Joe Dimino

    Dr. Parker:
    Thanks for the wealth of information on intuniv. Our Dr. just gave us intiuiv for our 5-year old son (just turned 5 on 12/8/04) and we are combing through the details of efficiency, safety, side effects and logistics. One big questions I have is this .. there is no research on children who are 5 using this drug. Obviously, our pediatrician, with 4 decades of experience in medicine, would not give us something harmful for our child, but do you think giving intuniv to a 5 year old is OK? Thanks in advance .. Joe

    • http://www.CorePsychBlog.com Dr Charles Parker

      Joe,
      It’s only ‘off label’ because it hasn’t been approved by the FDA for that age. Barring any other medical challenges there should be no problem – it’s always inappropriate for me to make a recommendation in this regard – I leave that one to your esteemed doc.
      cp

  • Robin Fink

    Dr. Parker,

    Thank you so much for your feedback!! My husband and I are new to this and we really just don’t know where and how to get started! We would like to get the testing done on our son Blayne but do not know where to begin! I would love to have a phone consult with you and give any information to you about our doctor if you would like to speak to him as well. Can you explain the process and how we can get started??

    I was a picky eater, had bowel issues and still do. Blayne is a picky eater and has some occassional constipation. He eats the food I put in front of him most of the time, he loves fresh veggies, just doesn’t eat them cooked! He is not a big milk drinker at all and only drinks chocolate milk on occasion. When he was a little younger we gave him Boost alot to give him the added protein, ect. He’s on very good multivitamins and he has been taking Coromega for about 7 months now. We have always given him some form of fish oil, I even took it during my pregnancy!!

    After 4 nights on the 2 mg dose of Intuniv, we are still experiencing the night waking. It’s 3 times a night or so, however, that is not unusual for our son. He wakes up wanting water, to use the bathroom, or to tell us about a nightmare. He was also diagnosed with mild Anxiety. To us and our doctors the Anxiety is not enough to tack on another medication for it. It’s nothing major in our eyes. He just sometimes thinks well beyond his years and worries about some things a child should not, ie, hearing someone talk about a Robber, ect. We also limit any television programs that would frighten him.

    Yesterday his teacher wrote a short note to me. She wanted me to know that he had an awesome day! He was very focused, attentive, and very motivated!!! :) It seems we are making some wonderful progress with the intuniv!!!!

    I hope this additional information helps. Again, I’d love to find out how to have a consult with you and what testing can be done to benefit our child and better his treatment!!! :)

    • http://www.CorePsychBlog.com Dr Charles Parker

      Robin,
      With the many symptoms well beyond ADHD your guy is an excellent candidate for NT review. I have some suggestions about phone consults on this CorePsych page, and will send you an offline note to make it easier to connect. Glad to hear about the Intuniv, an excellent example of the more complicated ADHD presentations often covered by Intuniv.
      cp

      • http://www.ADHDRollerCoaster.com Gina Pera

        Parents — If you at all possibly can, I HIGHLY recommend pursuing the Neuro-Endocrine testing (or whatever form of the NT testing Dr. Parker recommends for you).

        It is easy to do — your child has to just spit and pee! Think of the fun they will have taking such a “test”! :-) And then you just pop it in the mail or UPS. Dr. Parker’s office e-mails a PDF containing the results to you, so you can refer to it during your phone consultation. (Remember…..your child can see these results, too. I think whether you’re an adult or a child, it helps immensely to see concrete “data” that correlates to your challenges. Otherwise, child or adult can be left feeling the judgment has been made subjectively or that it’s a character/moral judgment or just some “quack’s” opinion.)

        Dr. Parker and I have no business relationship. I am simply a fan of his, and I’ve also been a volunteer advocate in the ADHD community for many years. For way too long, I’ve observed way too many parents and adults struggle for years trying to zero in on specific issues covered by the testing.

        Let me assure you: It is a painful, tedious process playing “Pin the Meds on the Adult/Child with ADHD.” Too often, the side effects from the wrong medication or wrong dosage are interpreted by well-meaning people (therapists, teachers, etc.) as “personality problems.” That alone can send you down many wormholes. Moreover, many years of critical development are lost for the child. With adults seeking treatment, oftentimes marriages, jobs, and good will are lost as the person founders through treatment. Costs are HIGH and sometimes PERMANENT.

        I wish my husband (who has ADHD) and I had had such testing years ago — not to mention the “big picture” expertise of someone like Dr. Parker. It’s staggering to think of how much expense, grief, frustration, etc. this would have saved us.

        My husband is a molecular biologist — a hard-core scientist — and he’d be the first to say that the NeuroScience Inc. testing is still experimental on some level. Scientists and the entire medical community have a very high level of expectation about medical claims. So, if your physician has told you that this kind of testing does not give iron-clad results, well, there is some truth to that. What your physician probably does NOT understand, though, is this kind of testing provides a heckuva lot more reliable data than anything else we have available now — especially at this affordability. And especially when someone with Dr. Parker’s expertise interprets the data.

        I am “pro-medication” for ADHD, because I’ve seen the incredible results in thousands of people. That said, if I had a child who had been diagnosed with ADHD, I would NEVER start ANY medication treatment before performing the types of tests that Dr. Parker recommends. There are too many other baseline issues to address with non-medication strategies first. Plus, I would want some kind of “map” to see where we’re starting and where we should go, not to mention measure progress along the way.

        Even if you don’t have insurance (which, thankfully, usually covers this testing), it’s still a good investment in your child’s well-being. Relying solely on insurance-plan physicians who don’t understand the complexity of these issues can be a huge false economy. My advice from years of experience: Cut back on every other expenditure possible, and focus on this CORE issue. All else in life depends on a solid foundation of mental health and healthy brain functioning.

        And parents, remember that ADHD is 75 percent heritable. That means if a child has ADHD, chances are good that one or both of the parents was the biological donor. Studies show that children with ADHD whose parent has untreated ADHD have a harder time. So, if you hope to do the best for your child, it’s important to face your own ADHD challenges — or help your co-parent to face his/hers. ADHD is a family issue, and focusing solely on the child when a parent is also displaying ADHD symptoms seldom works out in the long-run. In fact, it can backfire horribly. For a whole host of reasons.

        Okay, end of lecture! :-) I just had to take advantage of this huge assembly of parents who are smart enough to find Dr. Parker’s blog and who obviously want the best for their children.

        Good luck, everyone, and please keep reading Dr. Parker’s blog, watching his YouTube videos, etc. You will gain a first-class education.

        Gina Pera, author
        Is It You, Me, or Adult A.D.D.?
        Stopping the Roller Coaster When Someone You Love Has Attention Deficit Disorder
        http://www.ADHDRollerCoaster.org

        • http://www.CorePsychBlog.com Dr Charles Parker

          Gina,
          What a pleasant surprise on a snowy Va Beach Saturday! Thanks so much for your candid, supportive, and correct remarks! It’s hard for me to remain neutral when we see the percentages of positive outcomes improve using applied neuroscientific testing, – for ADHD, depression, Asperger’s, ASD, developmental delay, even frankly psychotic presentations, all frequently have imbalances and significant neurophysiologic challenges that I have been missing for years. If the clinical condition has an emotional, behavioral or cognitive presentation, these NT findings and associated immune/hormone dysregulations will tell us more than we can find thru questionnaires or insightful questions. Most of the underlying ‘background noise,’ which ultimately proves to house the actual underlying causal factors, are chronic and almost completely silent.

          They don’t shout at us, just as ADD – without the H – didn’t for many years.

          While testing doesn’t cover everything, as these challenging presentations vary in complexity, it is surprising to me, even after working in the office for 40 years, what benefits accrue from improved details on the brain function side. As you so accurately point out, biomarkers don’t make the diagnosis, and functional neuroscience has very little to do with DSM-4, – as DSM-4 lives so much with surface labels, not biological function.

          The most interesting aspect I find in the application process is hooking the lab findings up with the available science on co-factors, and the underlying neurotransmitter biochemistry with the real clinical complaints. Brain SPECT scans are useful, but they provide only macro pictures of function that require an enormous guessing leap to suggest effective interventions for cellular improvements. So why not measure the cellular function precisely in the first place? Any evidence is helpful, but from an ROI [return on investment] perspective, I love this new science, and am appreciative that is working for you and your interesting husband – skepticism is welcome!

          Thanks – look forward to chatting soon,
          cp

          • http://www.ADHDRollerCoaster.com Gina Pera

            You’re right, Dr. Parker. Journalists (that’s my profession) and scientists (my husband’s) are typically skeptical. As the scientists say, “Extraordinary claims require extraordinary proof.”

            But the smart journalists and scientists keep an open mind as they test out the claims. They also bring a large amount of real-world practicality and compassion to topics such as this. Lacking perfect metrics and diagnostics for these very complex brain/body issues, we must be unwilling to let the perfect be the enemy of the good.

            The more data we can gather — from biomarkers, interviews, third-party feedback (teachers, parents, siblings, etc.) — the better. Real lives do depend on it.

            Thanks for being here.
            g

            • http://www.CorePsychBlog.com Dr Charles Parker

              Gina-
              As my old buddy Aldous said: “Experience is not what happens to you – it’s how you interpret what happens to you.”–Aldous Huxley

              The new science of precise laboratory measurement is rapidly changing how we interpret commonplace observations – the illusion of perfect implies, as you so accurately point out, reductionistic, only linear thinking. Reductionism lost considerable significance in the history of scientific thought with the study of particle physics in the 1930s following Heisenberg and his Uncertainty Principle – a most interesting perspective, which introduces the concept of time and change to the most precise measurements. Werner was awarded the Nobel Prize in Physics in 1932.
              Well said!,
              cp

        • David

          Sold! and now am motivated enough to overcome procrastination. This donkey has too many ineffective pinholes in his butt. I will call Caitlin in AM. LUG dh

          • http://www.CorePsychBlog.com Dr Charles Parker

            David,
            You will love it, coming from your scientific background.
            cp

          • http://www.ADHDRollerCoaster.com Gina Pera

            Data is always important. My husband had the benefit of me being a regular Sherlock Holmes as he tried various Rx at various dosages. Not everyone has a person like that around. (And while I can’t say he was always grateful for the service during the process, he was after all the dust settled.)

            Moreover, ADHD itself means there are problems with observing phenomenon — internal and external. The right medication can enhance that ability, and the wrong medication (or the right, at the wrong dosage) can exacerbate those deficits.

            Good luck, David, and speedy healing of those pinholes. :-)
            g

  • Robin Fink

    Hi Dr. Parker,

    This is my first post here. I came across your blog while reading up on the new medication “Intuniv”! I have learned so much information on ADHD here. It has answered so many of my questions and I’ve been so excited to read the thoughts and concerns of others in my shoes and to know “I’m not alone” is the best feeling right now!!! My son is 6 years old and was put on this medication Jan 16th starting at 1mg. I have a family history of Tourette’s and ADHD so this was the best route for us at this time. We tried Medadate for a short period and the tics surfaced right away! He is very thin and short…..gets it honestly I might add :) He’s 40 lbs and because of his weight his Psychiatrist said we will probably stay at 2mg for a while. We have had some good changes thus far, and very quickly I might add!!! The only drawback for my son has been the extreme sleepiness. He has the occasional headache and stomach ache but the tiredness got the best of him shortly after starting the med so we moved his dose to night time per our doctors suggestion. He did have the night waking issue for a few days but it got better. He has just started the 2mg dose on the 23rd. He is waking up several times through out the night and is some what emotion less. Mornings are hard, he’s still very groggy upon waking so I’m trying to make sure I stick to that protein breakfast every day! I’m confident that the side effects will lessen with time, as they did with the 1 mg dose. My first question to you is, when do I become concerned that the 2mg is just “too much” for now and that we should back down to the 1 mg for a little longer? Also, should I move his does back to mornings? Will the effects be more beneficial to him or the same? I’ll leave it at night time if the effects will be the same for him but if he will get more out of the medication by taking that morning dose then I’d like to change him back to the am dose, however If he’s going to have a problem staying awake at school with the am dose then it only makes sense to stay with the way we are doing it!

    Any advice and information would be greatly appreciated! I look forward to hearing from you and reading more from you in the future :)

    • http://www.CorePsychBlog.com Dr Charles Parker

      Robin,
      Thanks for your remarks, and for joining us over here. When I see Tourette”s in my office I now have a different view than previously. I am determined to chase down the underlying metabolic reason – and that possible cause/reason, as I have repeatedly suggested is a strong possibility on this post [and indeed the other Intuniv posts] is likely immune disorder based. Without the details and only a couple of hints this guess is less likely to be accurate, but we collectively need to change our thinking from symptoms to causes. His symptom review will always result in repeated guesses. Lab findings and a more careful workup will bring more biomedical info that significantly improves prognosis.

      The immunity challenge, often associated with GI issues we have so often taken for granted as insignificant, can be addressed with testing quite easliy, and we have often chased these challenges down by a simple phone consult – and can work with your doc long distance.

      The findings that pique my interest:
      1. Tourette’s
      2. Reaction to meds that appears unpredictable
      3. His and your [genetic] thin and short stature – would ask about head and body disproportions
      4. Wonder about picky eater, bowel changes, stomach issues, hx of nausea, hx of waking with nausea,

      Even with all of these negative on the surface, he may not have inflammation per se, but could simply have a toxic reaction, all of which can be measured.

      Regarding the Intuniv: You and your doc are already on the right track. He should be better over time with the AM dose, it does take time, and in the meantime he might be best at a lower dose as he is only 6, and isn’t worried about going to college next year ;-) – that one I leave to your judgment with your doc.

      Hope this helps,
      cp

  • http://fdlpsychiatry.com Jeffrey T Junig MD PHD

    Dr Parker, I reviewed your background with interest this evening; I have a complicated bacground but now ‘pay the bills’ as a solo practice psychiatrist. I am well-educated: MSTP Grant for my PhD and MD, and Boarded in Psychiatry and in Anesthesiolgy, I been recovering from opiate dependence for 16 years, and so the new medications that can be use to treat addiction are an area of significant interest.

    To be brief: I have a number of web sites where I educate people aboutt the proper use of the medication and the threatment choices in general. I try to provide the information that I would want to know, if onw of my chidren was addicted to opiates. I also sell recordings for studyging for the psych boards.

    I found your mixture of science and innovative transfer of information interesting, and have been looking for a collaborator for some time do do similar work with the epidemic of opiate dependence sweeping the country.. There are many NIH funding opportunities that I am noticing others using to prepare sites similar to what I have done for free.

    Do you ahve experience at running non-profits or at applyig for grant money? I have treamendous drive, but need heop focusing my efforts behind a good business plan. IF youare interested, please contact me at drj@fdlpsychiatry.com.

    Jeffrey T Junig MD PhD
    Psychiatrist and Owner, FDL Psychiatry
    Owner, Wisconsins Opiate Managemen Center http://www.wiscoonsinopiates..com
    Owner, Terminally Unique Publishing at http://www.terminallyuniquepublishing.com
    contains: http://www.shrinkboards.com for psych education, http://www.audiopsychiatry.com, http://www.soberaftersub.com

    My Web Sites: http://fdlpsychiatry.com (my psych practice)
    http://suboxonetalkzone.com a blog about buprenorphine and opiate dependence
    htto://suboxforum.com a forum for opiate addicts to rage against the machine
    http://soberaftersub.com ways ot get off Suboxoen whent the time is right
    http://bupeguide.com my e-bood about suboxone; I have a much larger one in the wings.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Jeff,
      Back to you at Linked in, let’s do keep in touch, we have many similar interests, not the least of which is finding the best way to get matters right.

      Have you had any experience with low dose Naltrexone for casein or gluten withdrawal?
      cp

  • Ellen

    Just found this website and have thoroughly enjoyed reading the questions and responses from the doctor! Sharing in your experiences is helpful to me, a mother to an almost 12 year old son with ADHD (since birth!). He is a fantastically bright and funny boy, athletic and gifted on-stage, and has the ability to be sweet and tender (towards siblings and me & his daddy) —but you rarely see it unless he is on his medication. If he is off of it, and just “himself,” he is irritated about something — anything, moody, cranky, and all of this comes out in how he speaks. Any old thing can set him off. He is defiant, willful, disrespectful. A year ago we sought out a child psychiatrist who instantly confirmed that he had ADHD, and prescribed for him Adderall XR. He has been on that for 1 year now, and when he is on it, he is a whole ‘nother child! His grades went to straight As, he’s relatively obedient and generally agreeable, definitely focused and the hyperactivity is all under control. I hate to phrase it this way, but he’s the son you always hoped you’d have! I can hardly complain –when he’s on the medication. The problem we are experiencing now is that every single meal time is a struggle. In 1 year, he has gained 1 pound, and that is because my husband & I stay on him 24/7 to eat, eat, eat. If it were left to him, he’d probably never eat! We have tried everything …. protein shakes, favorite high calorie foods, protein bars — he’s just “blah” to most everything, and he never was that way before. My younger son who is 2 1/2 years younger than him is now the same height and weight as him, and although it may just be that the younger son will naturally be bigger and taller than this child, it may also have something to do with the appetite suppression. So, we are looking to change his ADHD medication to a non-stimulant type drug, but do not want to sacrifice the successes he has experienced at school and in sports. We have seen his confidence soar as a result of the improvements and the accomplishments he has made in school, sports, his extra-curricular activities, this past year. I do not want to exchange one for the other. I’ve read great things about Intunev and Tenex but am skeptical of switching while school is still in session, because I’ve heard these other drugs take awhile to get up to speed in the system. Any advice? I have an appointment to discuss all of this with his pediatrician next week. Sorry to be so long-winded. Thanks for any information you can provide.
    Sincerely,
    Ellen

    • http://www.CorePsychBlog.com Dr Charles Parker

      Ellen,
      I do agree with you on the theme of don’t mess with success – from a point of view of dramatic change. My experience with Intuniv in the context of already successful intervention: combine meds for awhile and assess if the Intuniv does correct some of the other challenging attitudes. Further, I do prefer Vyvanse over Adderall, by far, as your medical team can dial it in for ~12 hr DOE watching the Sides of the Therapeutic Window.

      Stimulants don’t have long term side effects unless they are incorrectly titrated, and it sounds like he is in an excellent titration zone at this time.
      cp

      • http://www.ADHDRollerCoaster.com Gina Pera

        Good point about maybe trying Vyvanse, Dr. Parker.

        So many people seem to think that all stimulants are alike. So, if one isn’t optimal, they go to a non-stimulant choice.

        But in fact, it often takes trials with several different formulations and delivery systems to find the right choice.

        Gina

        • http://www.CorePsychBlog.com Dr Charles Parker

          Gina,
          Thanks for weighing in, you’ve been hearing these reports from many in your exposure to hundreds of caretakers and interested parents through your own speaking and writing at ADHD Roller Coaster. Appreciate your input!
          cp

      • Ellen

        Dr. Parker ~ Thank you for your reply, and Gina too! Some follow-up questions so I am sure I understand correctly. Would you suggest I try to switch my son to Vyvanse, thereby staying w/in the stimulant family, rather than dramatically change him to a non-stimulant like Intuniv? (Incidentally, I’ve just read up on Vyvanse on the internet, and it does seem like a much more well-tolerated stimulant ….. still, the potential for decreased appetite concerns me.) Or, leave him on Adderall XR and incorporate the Intuniv? His appointment is on Wednesday, and I just wanted to know what to bring up with his pediatrician. Also, is the periactin that you cite as being useful in jumpstarting the appetite ok for use in patients taking Adderall, which he is on now? I know that lots of over-the-counter meds are not ok for use in conjuction with that particular drug. I suppose on other thing I didn’t bring up is duration of symptom control. Currently, he gets about 12 good hours with his Adderall XR, which is great for MOST days. The only time we have a problem is when/if he has a late baseball game (one that starts at 7:30-8:00pm). If I have given him his pill at 8:00 am before school, we can guarantee it’s going to wear off sometime during the 1st or 2nd inning of play. He does his best to harness his attention span, but everyone can see a different player out there. Late games are a killer ….. :[ Does having this information change your mind about what you suggest we do? Can’t thank you enough for your input! What a blessing this blogspot is!!

        • http://www.CorePsychBlog.com Dr Charles Parker

          Ellen-
          1. Periactin is ok, has to run thru your doc.
          2. Vyvanse is a good alternative to Adderall, better in many respects, less appetite suppression, still has to be taken with protein breakfast.
          3. Intuniv ok with any of these.
          4. Usually, to get 12 hr from Adderall the appetite does go down – because it’s a bit out the top of The Therapeutic Window – and titrating that dosage downward, possibly with a low AMP dose in the PM, may completely improve both the drop and the appetite without Periactin.

          On record: we are simply saying there are several reasonable additional alternatives that bear consideration if you get stumped, and Vyvanse is one of them in this context. I’m sure I speak for Gina when I say that our collective mission is education on the larger scale, not rendering specific treatment advice – there are just too many variables – most especially the great likelihood of significant metabolic noise humming in the background.

          Glad you have a few more paths to consider!
          cp

          • Ellen

            Just a quick update. Saw the pediatrician on Wednesday – discussed many options. She was very impressed with my “knowledge” of so many things (I had to confess I had learned a lot on this blog!). At any rate, we decided to leave my son on the Adderall, and phase in the Intuniv (1mg) …. go for a week, then step it up to 2mg, go for another week, then step it to 3mg. When we are somewhere in the 2nd week on Intuniv, possibly at the start of the 3rd week, we are going to step down his Adderall XR to 10 mg (he’s on 20mg currently). We’ll go with that for a couple of weeks — then evaluate. The target plan is to get him off the Adderall completely, but we want to move in that direction slowly, so we can tell, step-by-step, which med is accomplishing what. I can say after having only taken 4 Intunivs (he takes 1x nightly), we are so far doing well — and not experiencing the drowsiness that I was worried about! It seems to make a difference between the patients that take in the morning and the patients that take at night. I have him take it at about 6:30-7pm, and he goes to bed somewhere around 9 on a normal night. I will keep in touch!

            • http://www.CorePsychBlog.com Dr Charles Parker

              Ellen,
              Solid, thanks! Your report matches what others are saying about the PM dosing and it’s good to have some options right at your fingertips. Sounds like your doc is terrific!
              cp

  • Carrie

    Hi Dr. Parker,

    Just wanted to give you an update on my son’s progress through treatment with Intuniv and Strattera. I posted just after Christmas, and raved about the wonderful change we saw in our son once he started Intuniv (we added it to his Strattera dosage of 50 mg. daily).

    After the new year, on the advice of our neurologist, we tried taking him off the Strattera to see how he would do on the Intuniv alone. We had seen so much difference with Intuniv that we wondered if he even needed anything else.

    But apparently he needs both.

    Although his behavior on the Intuniv alone was still MUCH better than on the Strattera alone, we, his teachers, and his counselor noticed an obvious backslide into some of his previous anxious and aggresive behaviors. Interestingly though, his tics did not return at all, so the Intuniv is obviously taking care of that. But he went from doing his work every day to not being able to focus as well on his work, got more easily distracted, and also very emotional at times. I really began to see some of his old aggressive, moody, and frustrated behaviours at home as well. So after 2 weeks without the Strattera we have started him on it again at 25 mg for now and then will up it back to 50 next week.

    I am disappointed that the Intuniv alone did not seem to be working, as I really really hate having to give my 8 yr old 3 pills every morning (2- 25′s of Strattera + 1- 3mg Intuniv), even though I know they are helping him. It is hard when your child takes more meds than you do.

    I am hopeful this will return him to the way he was before Christmas – happy, sociable, easy-going, and hard-working.

    So questions: he is still really really drowsy sometimes. He often falls asleep in the car on the way home from school and even fell asleep in the principal’s office while waiting for me one day. Should he still be this sleepy after 1 full month on the Intuniv (3 mg)?

    He also seems much more constipated than usual and often screams because his bowel movements are sometime really difficult.

    I am still searching for various proteins he will eat for breakfast so perhaps that will help everything once that becomes more routine.

    Thanks so much for your very informative blog – I read it often. It is so fascinating to me how the brain works!

    • http://www.CorePsychBlog.com Dr Charles Parker

      Carrie,
      Thanks for your kind remarks! As you know I don’t want to tell you what specifically to do, but find in my own practice that the bowel issues always complicate the response. Now you know that I absolutely don’t like categorical remarks, so ‘always’ may sound a bit emphatic, but, as they say, ‘it is what it is…’ With drowsy ongoing, I strongly consider going back down if it continues to the prev dose.

      Flaxseed meal in the AM, one to two tablespoons with breakfast, and Omega 3 Fatty Acids [fish oil] in the 2000 mg range could significantly help with regularity and moods. Researchers are using 03FA at Harvard for mood stabilization, and studies do show they help with ADHD. Do read this CorePsych Blog breakfast post to consider protein options.
      cp

      • Carrie

        Thank you for your quick response, Dr. Parker. I just wanted to say that I appreciate all your help with complete and total strangers such as myself, who have given you no recompense or incentive for helping. While you may sometimes feel like our posts are just words on a blog – and you get so many of the same words over and over! – from the nameless world of the computer, we as real people with real difficulties truly appreciate all that you do. I have learned so much from this blog and that knowledge is helping our real-life family daily in a true and meaningful way, and is helping us make a better world for our troubled child.

        I will try the flaxseed oil. We have been doing the fish oil for years – even my 3 year old daughter gets it. Tried the protein power breakfast this a.m. – not a hit but will keep trying.

        Weirdly, since I posted only a couple of days ago, my son’s drowsiness seems to have diappeared. But it may be back tomorrow, who knows. It is no longer a daily occurence. I think we’ll stay at 3 mg this month and if it continues we will drop it back to 2. Since we have added the Strattera back he is definitely doing better, even though we aren’t up to that target dose yet. Maybe for us the Intuniv+Strattera is the magic combo.

        My son’s report card this term was much much better in almost every category. I am daily amazed and grateful for these medications and the assistance they give. His self-esteem is so much better, and he greets every day with a smile. To sum it all up, I can definitely say that where once his glass was half-empty, now it is half-full.

        • http://www.CorePsychBlog.com Dr Charles Parker

          Carrie,
          As they say in the streets, very cool! Thanks for your kind feedback, I just love hearing people getting the details straight, and when they do the plan most often does come together.

          One quick point [without chasing down my previous response], – I usually don’t recommend flaxseed *oil,* because it is high in Omega 6 fatty acids [06FA] which are pro-inflammatory with increased AA [arachidonic acid], – actually after we measure these as indicated, with Metametrix at this last link. Yes, O6FA but may required in the long run to balance 03FA, but on the front end we go with the meal…

          Flaxseed *Meal* is available in most grocery stores [on the flour aisle, down near the corn meal - not *Seed* unless you grind it yourself], – and is useful for constipation, with both soluble and insoluble fiber, it is innocent, with no problems, except being too mild for the job. Dose: 1tblsp – 2 in the AM eggs or cereal, often works like a charm even with challenged transit times. Not recommended for regular increased frequency – that’s another problem.
          cp

          • http://www.ADHDRollerCoaster.com Gina Pera

            Interesting bit about flaxseed oil — I didn’t know that. I hear from many people who think that flaxseed oil is somehow healthier than fish oil, for getting omega-3s. But I’ve read (perhaps on your blog, Dr. Parker) that flaxseed oil may not produce the desired Omega-3s as well as fish oil does — something about the conversion process.

            May I take this opportunity to mention MAGNESIUM? Americans are largely deficient in this key mineral, and limited study has shown that kids with ADHD might be particularly deficient.

            Why do I mention this here? Because magnesium deficiency can be a factor in constipation. Milk of Magnesia acts as a laxative, but that’s not a good way to supplement (this actually depletes magnesium). The more absorbable forms of magnesium are best — glycinate, citrate, etc.

            I’ve also known adults who’ve experienced relief from chronic muscle pains, Restless Legs Syndrome, migraines, and more from magnesium supplementation.

            I really need to write a blog post about this, instead of taking space here! :-) But with all these parents reading, I think it’s important for you to know that dairy products can exacerbate magnesium deficiencies, as calcium and magnesium need to be consumed in a balanced ratio.

            Gina

            • http://www.CorePsychBlog.com Dr Charles Parker

              Gina,
              Oh yeah! We see magnesium issues very often, and can see them with bowel issues, or without obvious bowel issues. Excellent point on the calcium connection as many just do the calcium, and miss the magnesium. Interesting how many come around quite quickly with Mg supplementation, and how it helps acid base balance, calming inflammation. Good idea on the post – we both should write on Mg – and compare notes! The muscle pains can show as jaw tightening, grinding teeth, restless legs, and almost always have frank bowel issues associated: IBS-C or D

              At the health food store for adults: Try CALM, with magnesium citrate… a bit expensive but tastes great, and works to help with acid base balance issues.

              You my friend, with your insightful remarks, are absolutely never taking space – anywhere! ;-)
              cp

            • http://www.ADHDRollerCoaster.com Gina Pera

              Thanks, Dr. P!

              Good point about the acid balance. I should read up on that.

              I do take my mag citrate (in powder form) with a little lemon juice. I hope that does the trick, but need to verify that.
              g

            • http://www.CorePsychBlog.com Dr Charles Parker

              Gina,
              Mg Citrate is good in any form, and while I haven’t sipped a cup of warm *Calm* in some time, I seem to recall it was flavored with lemon.
              cp

  • Janis

    Hi, I am in the process of getting my Fifth-grade son on Intuniv. He has all the classic symptomos of ADHD and his self-esteem has plummted to the point that we are all fighting and crying all the time. I have had him in behavioral therapy for four months now, and while it has been helping, he still has anger issues, mood swings, irritability in the morning, and an inability to stay focused in school. His grades are average, occasionally below, sometimes above, he is a sweet, kind, funny kid, however he is socially immature and a target for teachers to pick on him when he isn’t paying attention as this leads to distracting the other students. I am praying that this medication, being prescribed by both his pediatric neurologist and recommended by his behavioral therapist, will raise his self-esteem so that we are a happy family again and he will be ready for sixth grade. My question is this: Will he have to be on this for the rest of his life? Thanks for listening. I have learned a lot through this blog.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Janis,
      My inevitable answer with this basic question is always the same: I dunno. My focus is what to do now – and having made pronouncements in my younger years I now fall back on the wisdom of missing the mark simply because the years ahead bring so many different variables. My suggestion: Get tight with your doc, see if the new brain refraction works, and use those new glasses as long as it makes sense.
      cp

  • http://www.corepsychblog.com/2009/07/intuniv-for-adhd-understanding-tenex-guanfacine-and-alpha-2/ Sandy

    Hi Dr. Parker,
    I wrote in on December 23. After discussion with our docter, she is convinced that we can do better for Rachel than she was doing on the Intuniv. She was still extremely sleepy, lethargic, and pale at 2mg. of the Intuniv. Doctor is putting her on lowest dose of Vyvanse and recommends just as you do to start slow and increase slowly even mixing with water. I was glad to see that this was a med you recommend and that my doctor seems to be on the same page as you. I was wondering if you could enlighten me further on the antidepressant, Mirtazapine 15mg. My daughter is definitely showing signs of anxiety, not sleeping at night, pulling her eyelashes out, sweaty palms, excessive worrying about school. We had such a horrible reaction to the Prozac that I just wanted to get your take on it. I did a search, but have not found any information on this site about it. Again, I appreciate your generous time and the help you give to so many. I see that this blog has grown and you are a source of comfort to many.
    Sandy

    • http://www.CorePsychBlog.com Dr Charles Parker

      Sandy,
      Honestly you need more of a workup for your girl. Pale, sweating, pulling eyelashes, reaction to prozac, reaction to Intuniv, do consider NT testing, as it will provide more answers. See Kate’s results here.
      cp

  • http://adventurestudio.com Kate Scholl

    I wanted to post an update on my son’s progress since starting the protocol prescribed by Dr. Parker based on his analysis of his NT results. We’ve had some interesting developments that I wanted to share with the members of this blog. He is now drinking soy milk instead of cow’s milk and he’s eating a protein breakfast EVERY day. He has been taking the supplements Kaviance, TrevaCor and the using the Taurine spray. Prior to that, he was taking 2mg of Intuniv with pretty good results….I was definitely seeing improvement, but nothing even close to what I’ve witnessed this past week. Here’s the twist – we ran out of Intuniv and we were unable to get a refill right away due to bad weather. Then the pharmacy ran out and I was going to have to wait another day. Jack had a great week at school and his whole demeanor has improved 100%
    Thanks for your help!

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kate,
      Music to my ears! After all the struggles and with just a few days, terrific!! – & thanks for sharing
      cp

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kate –
      Sounds great!!! Love it. Readers: Remember these comments follow a good course of evidence. We don’t make any recommendations without solid facts.
      Thanks again!
      cp

      • http://adventurestudio.com Kate Scholl

        I wanted to add a few more comments regarding my son’s improvement since beginning the new treatment protocol. His skin color has improved and he’s no longer fatigued. I think for the first time I’m seeing him with the “typical” amount of energy a boy his age usually has. He’s a little wound up, at times, but I think all of that will even out as we progress. Unlike before, he wakes up refreshed and ready to go without lots of whining, complaining and crying!! I am truly amazed at the change taking place in my son. At the start of the new year, he began attending a private Montessori school which is a better fit for him. His teacher told me yesterday that since he started the supplements, he has not had a meltdown and his focus has improved already.
        I was hoping you would speak about the long-term results of treatment plans that have come about as a result of NT testing, especially for kids like mine, who do not respond well to traditional treatments. As you know, my son’s NT results revealed specifically why none of the stimulant meds worked for him. I’m beginning to understand (as much as a non-medical person can) the “what” and the “why” of my son’s brain function.
        Regarding food – I’ve long been a healthy eater, but since my son was such a picky eater, I fell short on getting the right foods in him. We had so many battles, I often “gave in” when it came to food. Now that I know how foods can affect him, particularly milk protein, I’m committed to being far more diligent about his diet. Fortunately, we have a Whole Foods which has many good-tasting, organic products that my son actually likes. I’m willing to spend the extra money if it means a healthier, happier kid. In fact, the entire family is feeling better since eliminating many of the preservatives and additives from our daily foods.
        I first joined this blog on the day my son was essentially asked to leave his 1st grade private school until we could determine what was wrong with him and get him on the right medication. The school counselor even mentioned that he might have a bit of a psychosis – I remember thinking, “Is that like being a little bit pregnant!” I had the feeling that continuing to try one med after another was like changing seats on the Titanic. Regardless of our efforts, we were still going down. That’s the day I discovered Dr. Parker’s YouTube videos and was directed to this site. The NT testing was the lifeboat we needed!
        Thanks again, Dr. Parker, for doing what you do! You are planting the seeds of change indeed!

        • http://www.CorePsychBlog.com Dr Charles Parker

          Kate,
          Love it when it all works as it should, and appreciate your sharing your personal experience with our readers and those interested in more comprehensive approaches that do work through understanding the evidence from additional resources.

          Long term results are terrific… once the antigens, the thorns, are out of the lion’s paw, we can heal internally, and the prognosis long term is terrific. The supplements will be diminished – and some will be dropped altogether, after subsequent re-measurement.

          Lucky they didn’t call him Asperger’s or Autistic, a favorite wastebasket for kids with metabolic challenges! And the Titanic metaphor works for me, been there done that – but no longer!
          Thanks again,
          cp

          • http://www.ADHDRollerCoaster.com Gina Pera

            Wow, that is such wonderful news, Kate.

            It breaks my heart that so many children (and adults) will never find these kinds of solutions. What a tragic waste.

            • http://www.CorePsychBlog.com Dr Charles Parker

              Gina,
              Same thoughts over here… When I am riding around the country doing presentations I look at those ‘challenged’ homes, either up in the Smoky Mountains, or down by the river in the Ohio farmlands, and think of those we are missing, – and keep thinking of ways to connect them with this useful info. Yes we will do a program on these matters!
              cp

            • http://www.ADHDRollerCoaster.com Gina Pera

              Yes, exactly, Dr. P.

              And I also think of kids in the well-heeled cities or even here in Silicon Valley, with the all-pasta and dairy diets, etc. Oy.
              g

            • http://adventurestudio.com Kate Scholl

              Information moves faster than the speed of light, but belief systems change very slowly. I read a quote the other day by George Patton: “If everyone is thinking alike, then somebody isn’t thinking.” If that doesn’t ring true with regard to this stuff, then how else do you explain it?

              Thanks Gina – I enjoy your posts.

  • Kris

    Dr. Parker,

    I have a 7 year old almost 8 year old son who has been diagnosed with severe ADHD since he was 5. We had suspected he was ADHD but they would not consider any testing etc until he was 5 years of age. For the past 2 years we have worked with several medications that have shown some symptoms control however my son has adverse reactions some severe including high blood pressure with most stimulants. We have also discovered on our journey that my son has a very fast metabolism in which any medications he takes tends to only last between 2-4 hour at the most especially long acting or extended release type medications. We have been through doctors galore finally found one we can relate to that will listen to us and focus on the problems. Main problems with our son is morning temper getting him just going in the morning, overall meanness for no reason and unable to focus and sit still all the time. Very defiant at times. He is an overall sweet, intelligent boy who when he can focus is just loving and the most sincere boy. We have had him on Vyvanse 30mg 2x per day for the past 6 months, in which it seems to control most of his symptoms however it’s a tune in process… poor baby just weeks prior to Christmas break started with more symptoms of outbursts and unable to focus. His grades started slipping again. Dr decided to place him on Intuniv along with his Vyvance therapy 2x per day as a test to see if this would work. Sure enough we started to see things calm down, he was able to focus, first time I ever even on the Vyvance see him put together an entire Lego set in one sitting. I am truely amazed. School even reports he has greatly improved and they are proud to report he is one of the better students in the class right now. Grades, writing and just over all paying attention has greatly improved. However there is a large concern with us that he is taking too much medication. We worry constantly about blood pressure due to all of his prior meds and his reactions to meds. We are kind of reserved but hopeful this is going to be the true therapy that helps him now that we are seeing good results we want to believe it will be the key to his own success and be a true success story. My question for you is that we had discussed possibility of taking him off Vyvance or reducing it to 1x per day or only taking Intuniv to see how it will work. I wanted to know have you had any cases where someone has only taken Intuniv and has done as well. I know every child is different, again we worry he takes too many meds all the time. Any information would be greatly helpful. Thank you.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kris -
      You are recording clear metabolic problems that need more careful review to discover the specific underlying problems – these are the markers:
      1. Adverse reactions, severe, with HBP.
      2. Markedly odd metabolic rate – this is covered carefully in my new book.
      3. Vyvanse DOE good, then appears to deteriorate – Vyvanse rarely needs adjustment unless associated with a moving Therapeutic Window, secondary to metabolic issues.
      4. Intuniv is often surprisingly helpful, does cover a different neurotransmitter system: glutamate.

      To answer your two bottom line questions – but am not recommending either as I am not there, and those issues are for you and your doc:
      1. No problem using the two together.
      2. I have had good results [with some] going over only to monotherapy, as have my research colleagues – noted in several other answers to other comments here.

      If you remain in any kind of quandary don’t hesitate to get more testing – many other options can become useful when you have more comprehensive information.
      cp

  • cally

    I posted a month or so ago just as my daughter was beginning the Intuniv journey. We are currently on our 4th week of 3 mg of Intuniv (we have not tried 4 mg). The major angry, irritable, irritating behavioral stuff is markedly decreased. She does not get sleepy during the day, etc. However, she seems REALLY forgetful and is having some major issues with reading comprehension, which have always been an issue, but are severe right now. She also seems somewhat unmotivated to do things that normally bring her pleasure. There has also been more night waking, which previously was not an issue.

    I don’t think I’d mentioned before that my daughter also has Asperger’s and during her SPECT testing, was found to be in the 99th percentile of severity with the ADHD (Ring of Fire at that!) She is on some other meds, one of which (Celexa) we’d started a week or so before the Intuniv.

    The meds my daughter uses are 63 of Concerta, 150 of Lamictal (for the ring of fire moods), 10 mg Celexa and 3 mg Intuniv. I have been vascillating between 63 and 54 on the Concerta and am not sure if that is the cause of her reading and motivation issues or if she is just on too many meds in general. I tried 36 one day and it was if she was on no Concerta–not good. I am resigned to the fact, that due to my daughter’s complex issues, we will not achieve good function with monotherapy, but the current situation seems not to be working as well as I’d like either. We also use fish oils, good vites, other supplements to help support her. I am most wondering about the necessity of the Lamictal.

    Do you have any input of ideas I could mention to her doctor? I’m not sure where to start, but yet don’t want her yanked off a med that might work with a little tweaking. My doctor is excellent about listening and advising, but I’m not sure what to even ask at this point.

    Thank you for your time.

    Cally

    • http://www.CorePsychBlog.com Dr Charles Parker

      Cally,
      Remember: “Ring of Fire” is an Amen term, having to do with the underlying diffuse cortical hyperperfusion, the term I prefer, as do the rest of the nuclear medicine docs – because it tells you something specific about brain function, is not purely descriptive [dealing with brain appearances], and clearly diminishes the evocative response with patients. Yes, my term is more technical, but that hypermetabolic state tells us something about what we can do next.

      My experience, having seen many hypermetabolic brains with their owners [and repeatedly seen this conundrum following SPECT brain imaging with Amen's offices] is that these folks all need the next step after SPECT: specific neurotransmitter {NT] testing. Now I can predict with some certainty that the excitatory neurotransmitters will be high, that’s easy after seeing the SPECT hyperperfusion, but your most informed and clinically useful metabolic information will be: specifically which of those excitatory NTs are up, and, most importantly, where is my new friend, urinary histamine. It will likely be up, but, even if it isn’t, the inevitable imbalances will give you multiple options to address that will help the pharma do it’s job.

      If histamine is up, IgG4 testing will be in order and from there you can take even more specific action with offending food antigens identified therein. Neuroscience evidence changes thinking! Deeper, more accurate neuroscience evidence is your next step – then the meds and much more will become more self evident.

      BTW, if that next step proves confusing or non-responsive there are several other very interesting tests available which require a bit more explanation [due to evolved understanding of cellular physiology] for even more challenging presentations.

      Bottom line, more testing, not more meds at this moment from my chair in this office.
      cp

      • cally

        Thank you Dr Parker!

        As a matter of fact, we did NeuroScience testing back in 2006 with the following out of range results: Serotonin low (113.5 with a rr of 175-225), GABA high (6.2 with rr of 1.5-4.0), Glutamine high (1483.7 with rr of 150-400), Glutamate high (37.1, rr 10-25), PEA high (863.8, rr 175-350), Histamine high (42.4, rr 10-25).

        I know these results are very old, but what direction would those send you if they were current? I suppose I need to redo all the testing and go from there. Back in 1996 I did try the products recommended to address my dd’s results but unfortunately we saw no results and it was SUCH a struggle to use the sprays (my daughter’s sense of taste is so exquisitely sensitive) that after a couple of months of no real changes, I gave up.

        I do realize that a lot more study has been done since 2006, so perhaps we’d have better luck now. You’ve given me much to think about with your reply.

        Thank you.

        Cally

        • http://www.CorePsychBlog.com Dr Charles Parker

          Cally,
          The more I do NT testing the more I jump to Histamine levels first when a quick look at the numbers indicates significant global disarray with many of the others. This hist level is ‘out the roof,’ way out of the top of the range of ‘normal’ no matter when it was first read – and should be followed up soon with a Food Sensitivities test – focused on the IgG4 antibodies to get the basic foods out of the way.

          Yes, 4 years could herald a significant change in the numbers, and a redo is quite in order, but will very likely reveal little improvement in that hist level. Histamine is a prime marker for immune dysfunction, and often associated with leaky gut which changes nutrition and regularly diminishes amino acid levels.

          If the sprays are a problem you need more options… and there are several, depending on what your current findings are – wouldn’t recommend just using those old results if you plan specific intervention.
          cp

          • cally

            Thanks again Dr Parker,

            You have no idea how much I am appreciating your input right now. I hate imposing on your time, but I feel it is so important right now, and don’t have another place to turn at the moment.

            We have been working on my dd’s gut issues since she was 3. She was on the gluten free/casein free diet for 3.5 years, has had extensive allergy testing/treatment from the Block Center in Texas, as well as other more alternative treatments for food allergies, for which there was a looooong list. We have done many “gut protocols” along the way and do in fact still use probiotics, and biomdedical treatments to address the gut etc. In the last few years, the severe eczema and “asthma cough” have all but disappeared, although I’m not smug enough to think everything is resolved.

            Which NeuroScience panel would you recommend we use at this point? I do plan to pursue this further as I am fully committed to helping my daughter be as comfortable and successful as possible.

            Thank you.

            Cally

            • http://www.CorePsychBlog.com Dr Charles Parker

              Cally,
              When you report that you have had many more tests over the years, then I back off from simple, more basic, approaches, – and start to consider bigger, more comprehensive approaches. Neuroscience has 110 food sensitivity, it’s a blood study, but honestly, when you have a multiplicity of issues, I would turn to the Triad with Metametrix, recently updated on the Neuroscience page, with some excellent educational links there. The Triad covers nutrition and the downstream effects of the immune function. Also might consider the more expensive but useful ELISA testing noted on the Useful References page. I like the Triad first, and you could do the bloodspot as it would be significantly easier than finding a blood draw site.

              Simply said: I would have to know more to give you better specifics on where to turn next.. but these are some suggestions that do provide additional information.
              cp

            • http://www.ADHDRollerCoaster.com Gina Pera

              Dr. Parker,

              Perhaps some readers don’t realize that you offer consulting services by phone. I know you do this with the various NeuroScience testing, but I’m not sure how far you go into other treatment issues. Do you prefer that people work with a local physician, who would receive copies of these reports, or do you actually offer full consulting services via telephone?

              In my advocacy work, I hear from people all over the country (and the world), and I know that many people face very limited medical choices in their communities, especially with complex ADHD+ cases. It can be a pretty desperate situation.

              thanks,
              Gina

            • http://www.CorePsychBlog.com Dr Charles Parker

              Gina,
              Appreciate your asking! Yes, I do provide consultation by phone – diagnosis, lab testing, and recommendations that won’t create a problem with crossing boundaries medically. For the medical piece we do everything we can to work with the doc on site. Some do come out to Va Beach so that I can write the meds, but most often meds aren’t the underlying problem. With questionnaires and testing + a phone review, we can suggest a number of additional interventions – for ADHD and the other issues such as immune dysregulation and hormone balance – just can’t write for meds unless seen in Va Beach.

              With the testing it often becomes quite obvious why meds aren’t working as expected – because hard evidence lives below what others are testing.

              Best to simply drop an email to Caitlin on the Services page, and we can set up anyone interested in comprehensive discussion of the problems.
              cp
              PS: Will be providing a cost saving opportunity to those who attend the Virtual Holistic Conference on first consultations. Thanks again…

            • cally

              Dr Parker,

              I had some nice exchanges with you a month ago regarding my daughter’s wild NS results from 4 years ago:
              Serotonin low (113.5 with a rr of 175-225), GABA high (6.2 with rr of 1.5-4.0), Glutamine high (1483.7 with rr of 150-400), Glutamate high (37.1, rr 10-25), PEA high (863.8, rr 175-350), Histamine high (42.4, rr 10-25).

              You were particularly concerned with the histamine. I redid the tests and got the results this afternoon:
              Epinephrine, L-8.9; Norepinephrine, L 13.0; Dopamine, Optimal 158.7, Serotonin, L-78.2; Glycine, Optimal 979; GABA, Optimal 2.9; Glutamate, Optimal 32.3; PEA, Optimal 61.9; Histamine, Optimal 18.3.

              As you can see—almost a completely different result. NS recommended Tyrosine spray, AdreCor and Serene. I have a few questions, though. Would it be safe to add the 5 HTP in a child who is already on 10mg of Celexa? Also, could I use Tyrosine caps instead of spray as my daughter has an exquisitely sensitive palate, which was an issue the last time we tried the sprays? Finally, my daughter is already on all the vitamins in the AdreCor (Kirkman Labs Nu Thera with P5P, plus nasal methyl B12 spray) so I see little point in adding more multi vites. How significant are the few aminos that are listed as part of the ingredients? Could I simply add those in as separate supplements (I own a supplement business for kids with ASD disorders so acquiring these are no problem for me.)

              Any guidance is greatly appreciated. I must say it was nice to get some testing back that wasn’t a total trainwreck! Also, we are LOVING the Intuniv! No longer do we have a monster living in our house! And reading scores have gone WAY WAY WAAAAAAAAAY UP! We’re loving it.

              Thanks again,

              Cally

            • http://www.CorePsychBlog.com Dr Charles Parker

              Cally,
              I won’t have time to cover all the details, but in short, I do start any review by focusing on a high Histamine – at that level [42.4] you have to get with the immunity issues. So what exactly were her immunity issues, what testing did you do, and how did you resolve the challenges over time?

              The 5HTP spray can be mixed with the Celexa, yet therein lies the rub. As soon as you mix the NTs with the regular meds, whoever is watching must be completely informed about interaction/accumulation possibilities. I have mixed them carefully, know that others do, and don’t worry about serotonin syndrome when there is no serotonin! On the other hand, I do strongly recommend watching any children, especially the ASD folks for dysregulations that can precipitate regressions. This is the same procedure as any medication augmentation strategy.

              I have one ASD child who comes to mind with several different meds including Intuniv, a stimulant and a small dose of antidepressant [likely Celexa] – and as we have trimmed up the NTs we have seen side effects from the other meds, as if they are overdosed, with the result we have been able to significantly modify the treatment with the psych meds. which often appear less forgiving than the NTs.

              The few aminos in the side ingredients: Not a problem, not enough for concern, but just enough for some positive effect.

              Glad the Intuniv is working! As I indicated elsewhere it looks like Intuniv does have some special benefit for ASD kids, and have seen the progress with those in my office as well. Thanks for getting back with us.
              cp

  • sue

    I was wondering what your thoughts were on concerta and intuniv given together…my son is on 2 mg of intuniv and 18 mg of concerta…..is it too much medication; he has been having some rapid blinking and he has been complaining of headaches….it this normal…he has only been on this for 2 weeks and he seems to want to take it before he goes to school…he is 12 years old and he says it is helping but I am worried about the side effects and if he really needs to be on 2 ADHD meds…thanks

    • http://www.CorePsychBlog.com Dr Charles Parker

      Sue,
      Regrettably there are no rules here that apply in every case, and there are way to many issues flying around in this kind of situation to offer specific cogent advice.

      On a larger scale: these meds together are not a problem. Tics with blinking are more likely Concerta than Intuniv, as we have been using guanfacine, the Intuniv parent compound, to treat tics for years. Suggest you call your doc, but don’t worry about the two meds. There are no interactions between those two, and in many cases togetherness seems helpful.
      cp

  • Hilary

    I am new to this site, and really looking for some answers. My son is ten years old and has been on Concerta, 54mg, for primarily inattentive ADD. He does not have any oppostional behaviors, ODD, anxiety, tics, etc. His doctor wanted to switch him to Intuniv due to his weight– he is a skinny guy. To be honest with you, I was very skeptical about a non-stimulant being effective for him. He started the 1mg nightly Intuniv a few weeks ago, and returned to school this week. I informed his teacher of the change, and asked for feedback. To my surprise, she stated she could not tell a difference between his being medicated on the Concerta and on the Intuniv. He seems a little keyed up and unfocused to me at home, but maybe he is better at pulling it together in school now that he is getting older. I relayed this to his doctor, who is keeping him at the 1mg. I guess I am still skeptical that this medication could be doing the trick. Is it likely that only 1mg is this effective? He is about five foot three inches tall, so not a small kid. He went on the Concerta in thrid grade, when he was having extreme difficulty staying caught up, and the Conerta made a night and day difference for him.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Hilary,
      Actually way too soon to tell on the Intuniv start – time will tell. Just a quick reminder: Intuniv clearly showed an excellent response for ADD symptoms alone – e.g. inattention. It’s not necessary to have the ‘mandatory’ ODD subset of symptoms for Intuniv to show an effective response. And the dose question: Same answer – time will tell. Weight guidelines are just that – guidelines not gospel. Take a look at this CorePsych Blog post on Intuniv Dosing for more info that might prove useful.

      And do not forget the Protein Breakfast! ;-)
      cp

    • http://www.ADHDRollerCoaster.com Gina Pera

      Hilary,

      It’s the primarily inattentive kids that teachers seem to overlook. With children whose ADHD presents more obviously and physically (not sitting still, blurting out answers, etc.), the difference between being on medication and off is more obvious.

      If you haven’t already thought of this — and you probably have! — it’s something to consider.

      At least, you could try some more objective “tests” at home — asking him to play a game that requires more focus, for example — and get more data.

      As for the weight concerns, I’m betting Dr. Parker has written elsewhere on his blog how these can be often be addressed while on a stimulant. There is a TON of information on this blog (including radio podcasts, etc.). It staggers the mind! lol!

      gina

      • http://www.CorePsychBlog.com Dr Charles Parker

        Gina,
        Thanks for weighing in on this subject – and reminding me to note one ‘medical’ intervention I have regularly used in the past: Periactin at 4mg 1/2 – 1 at bed. From children to old folks in nursing homes it will safely get the appetite going, and often is only needed for awhile whilst the appetite shifts back to the ‘on’ position. Thanks for reminding me about that one.
        cp

        • http://www.ADHDRollerCoaster.com Gina Pera

          Great tip!

          I’ve never understood why children on the stimulants lose weight when none of the adults I know do. I’ve often wondered if the dose is simply too high for the children and they aren’t able to give the kind of feedback that would indicate it.

          • http://www.CorePsychBlog.com Dr Charles Parker

            Gina,
            My take on this childhood comparison to adults: I think kids complain, and manipulate breakfast, and food much more than most realize, and parents don’t have solid alternatives for breakfast. As Michael Pollan points out: we are not paying attention to the long term consequences of dietary speed. No/little food at breakfast = gastric irritation = appetite suppression and a buzzy feeling – even with Vyvanse. Kids start young with their picky eating, do have significant allergies to the junk we are feeding, and very often go completely overlooked – until the flame-out is obvious.

            Incidentally: will be covering this during my presentation at the Virtual Holistic Conf with Hyman, Amen and many other outstanding presenters [Jan 26 & 27] – very soon! . Tomorrow I will be recording a podcast of my agenda with Jennifer Koretsky the hostess there, so drop over to hear that review soon – probably up by Thursday 1-14.

            My brief take on these matters: Medical professionals are lost in a profusion of innuendo, frank name calling and finger pointing about who is right regarding the correct approach many chronic illnesses, including ADHD. The functional folks say the traditional docs are daft, and the traditional docs who practice paleolithic medicine disdain the functional med docs as quacks. New brain and body science makes it simple: both are right, and both can be completely wrong. The answer is simple: measure carefully, prescribe specifically. Sorry, getting on my soapbox prematurely… – and I will be outlining specific ways traditional docs can measure variables more precisely during my presentation at the Holistic Conf.

            Hyman is a world famous functional medicine doc with a balanced view of matters. Amen is a traditional doc who uses new technology to watch brain function through imaging, and I am a traditional doc who has his feet planed firmly in both camps: brain imaging, functional medicine measurements with advanced micro laboratory techniques, and traditional psych meds – looking for what works best, period… holistic evidence provides holistic solutions. Neuroscience evidence changes thinking.

            And Gina, yes, kids often aren’t able to give good feedback, especially to those who don’t provide a format to evolve the discussion during evaluation and treatment.
            cp

        • Hilary

          Thanks for the feedback. We have been doing the high protein breakfasts and fish oils for years, and he typically eats very well. Here is an update– he went back to the doctor this week, and has gained FIVE pounds off the stimulant, which is wonderful. His teacher, who states she is paying special attention and watching him, indicates he is still doing well. He seems energetic and sometimes hyper at home, but is apparently pulling it together in settings where he needs to. I never thought he would do so well on a non-stimulant. He is still only on 1mg, and it is week four.

          • http://www.CorePsychBlog.com Dr Charles Parker

            Hey Hillary-
            Great news, and high five on the breakfast protein!
            cp

  • http://adventurestudio.com Kate Scholl

    Dr. Parker – It was a pleasure and a privilege to discuss my son with you. I feel energized about Jack’s prognosis and can’t wait to begin the interventions we discussed. To bring those following this string into the fold, Jack’s NT test showed an imbalance in his NTs that are more indicative of an auto-immune problem, which is likely causing his ADHD symptoms. Upon hanging up with Dr. Parker, I was struck by how my new-found knowledge quickly changed my view and understanding of ADHD. I always thought of ADHD as having a single cause, but due to variances in metabolism and personality, each person responded differently to treatment(s). My new understanding is that there is a group of common symptoms, with a wide variation of causes that can now be identified and treated in a more targeted approach. According to Dr. Parker’s (please correct me if I’m wrong) interpretation of Jack’s NT test results, his neurotransmitter imbalance is resulting from an auto-immune problem which will very likely resolve with specific changes to his diet and by adding very specific natural supplements to his daily routine. In fact, Jack’s test results helped to explain why he cannot tolerate stimulants and perhaps why the Intuniv is helping. The good news – there is much more we can do to improve Jack’s well being. I can’t wait to turn the page on this very long chapter in my little guy’s life. I highly recommend the NT testing if you desire more precise answers and better solutions. I must say that for the first time ever, the “dots” are connecting and I can see the bigger picture. It’s nothing short of amazing! It is stunning that this information is still not embraced more fully by the medical community at large. I will continue to post on Jack’s progress in an effort to do my part to shed light on the subject. Thanks again Dr. Parker – your enthusiasm about and respect for the patient as a whole person, is both refreshing and inspiring.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kate,
      Thanks for the update here – it’s so much fun everyday sorting out the variables in complex individuals with so much promise as the Jack guy. And with an informed Mom such as you… his prognosis is excellent with the facts that we now have. Just a little more info and I expect we can nail it.

      You got it exactly right – his elevated Histamine [up in immune dysfunction], the subtlety of his real GI issues, his Dopamine excess without AMP stimulants and his overall dysregulation with the other neurotransmitters encourages more careful immune review – with the Food Sensitivity panel for 110 foods. I did guess that it is Gluten, could be Casein, as those are the most frequent problems we see, and the most common foods with allergenic reactions. Time will tell.

      I very much look forward to our next visit! Thanks for weighing in and sharing your experience with our readers!
      cp

      • http://www.ADHDRollerCoaster.com Gina Pera

        Thanks for sharing your progress with other readers, Kate. I wish you and your son the best in continued progress.

        Dr. Parker, on the point of immune-system reactions, etc., I have a question, when you have a minute.

        From my amateur observation, it seems that there’s a higher incidence of allergic sensitivities in the ADHD population. How do we know that the symptoms are secondary to an immune-system reaction vs. the ADHD neurobiology itself CAUSING an immune system reaction — that is, overinterpreting the threat of the allergens?

        I’ve also seen a decrease in my husband’s allergies and physical sensitivities (to clothing tags, etc with magnesium supplementation. Years ago, I was visiting a house of a nutritionist when I had a severe allergic attack to his cat. He mixed up a drink of magnesium and juice for me. I drank it politely, fully expecting no relief from the sneezing and itchy eyes. But it worked almost immediately.

        Gina

        • http://www.CorePsychBlog.com Dr Charles Parker

          Hey Gina,
          Nope you are no amateur, – having heard all of this so often!

          My take on the question: Two amazing observations: ADHD is completely under diagnosed, you know that – and the reason is that we still aren’t asking the questions about function. Currently questions are vertically delivered from an observation tower at the airport rather than reported from the flight deck itself with the dials all working. Second point on your question…. sure seems that way. So many overlooked on both subsets.

          My new criteria is this: Some just turn around dramatically easily with ADHD once discovered – and no problem, they are out of the office and into our 3 mo med check protocol. The hard ones… they are the neurotransmitter measurement folks – and of those, immune dysregulation is high up there as comorbid fer sure, and possibly primary. We have been dropping med doses as we work out the other comorbid problems, so too early to tell if actually causal. Probably should run a study on fresh patients, break them out on the some specific refractory criteria, test them and run down the details, would be great fun and just might be helpful!

          Very interesting question Gina, have a great week!
          cp

          • http://www.ADHDRollerCoaster.com Gina Pera

            Thanks Dr. Parker. I appreciate your taking the time (again!) to explain that. Makes perfect sense.
            g

        • http://adventurestudio.com Kate Scholl

          Thanks Gina – I always enjoy your comments. I feel like we’re finally getting on track with Jack.

  • http://adventurestudio.com Kate Scholl

    My 7-year-old son, Jack, is now at 61/2 weeks on Intuniv. We are staying at 2mg and he has finally made it past the extreme groggy phase! Jack has ADHD with extreme oppositional/impulsive behaviors. We had very little luck on the stimulants and we were running out of options. We tried Strattera and it seemed to push him into a far more negative state so Intuniv was the next in line, so to speak. As each week passes and the side effects dissipate, I am beginning to see more balance in Jack’s ability to cope with life – on life’s terms. For the first time ever, he seems to have the ability to choose “how” to react when things do not go his way. We have a long way to go, but I do sense that we’re on the right track. The Intuniv is definitely a slower process than a stimulant, so the jury is still out. That said, I feel as though we are moving forward after many years of spinning our wheels or moving backwards. Those of us raising ADHD kids, especially the tough cases, tend to hold our breath with each new treatment since success seems to elude us. As for the NT test, I will be talking to Dr. Parker about Jack’s results later today. I am hopeful that his input will shed more light on Jack’s particular challenges. I will keep everyone posted once we know more. This sight has been a blessing for our family. In an age of “too much information” it’s hard to know who to trust. Corepsych and Dr. Amen’s site are tops!

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kate,
      Thanks for the opportunity to discuss Jack – naturally I won’t discuss the issues here, and will leave that to you if you wish. Bottom line: Very interesting example of more-than-meets-the-eye. Now it will be interesting to see how this next intervention process works out!
      Great talking to you!
      cp

  • Brandy Smith

    Hi there:
    I wanted to post an update about our Intuniv experince. I posted before Christmas about how worried I was about the grogginess when we increased to 2mg. I am happy to report that the extreme grogginess is all but gone. It did take longer on the 2mg to get over the tired “hump” (about 4 days with 1mg, a full 7 days on 2mg). She is back to her old self… actually has been waking up in the middle of the night lately. Also, we are beginning to see impulsive and hyperactive behaviour rear it’s ugly head. But, it’s also been two weeks off of school with cabin fever. So, we are going to stick with Intuniv 2mg for a couple of more weeks and talk with the teacher about how it is working in the classroom. Our main issue is still impulse control and hyperactivity. Inattention is less of an issue. Our Psych wants to move to Strattera next (if we decided Intuniv is not effective in the classroom). But I keep reading negative reports about it. Will stimulants (like the patch I keep reading about) help with impulse control and hyperactivity, or are they more for inattentive types. Thanks for this blog. I will continue to report our progress, since I do not see a lot of information out there about intuniv.

    Brandy Smith

    • http://www.CorePsychBlog.com Dr Charles Parker

      Brandy,
      Thanks for the update. My first choice for ADHD remains Vyvanse, and you can find much info here by simply Searching Vyvanse here. The patch is good from the DOE point of view, and is a good second choice. I have a post up on Daytrana patch as well with specific suggestions about that product – more than a year ago. Strattera is a third choice for me, having failed everything else, – and for complicated situations with poor response I always look at her neurotransmitters. A little evidence always goes a long way.

      Glad it’s working better for your girl… best wishes,
      cp

    • Denise

      Hi Brandy and Dr.Parker,

      My son has had side affects every time he went up a mg. Usually only lasted about 4-5 days and we were back to normal. Lower doses mostly just sleepiness, and a little dry mouth. When we went to 3mg he had a tummy ache the first couple days. All went away. It’s funny, my Doc wants to try Strattera as well, if Intuniv doesn’t work. Dr.Parker gave a nice reply to me about Strattera on this site that you may want to look up. I am not real keen on trying it either. I will have to talk to my Doc more on why the Strattera route next. As I noted in a previous post it may be because he knows I am also leary of stimulants. After more research though, I am willing to try them. We did not see a thing on 1mg or 2mg. On 3mg I have seen “windows” of improvement but nothing major. We just started 4mg last night. (son is 11yrs, 70lbs). I sure hope it works. Dr.Parker, I did talk to my Doc about NT’s. He doesn’t believe that we have the ability to actually measure them. I can’t really articulate his reasoning, but something about that we can’t really capture or measure them…I didn’t really get much further with him on that. Anyway, thank you again Dr.Parker for this forum and blog! Best wishes Brandy.

      Denise

      • http://www.CorePsychBlog.com Dr Charles Parker

        Denise,
        Thanks for trying with your doc – he might like the ‘Biomarker’ pdf at the CorePsych Blog Neuroscience page – he is working under the impression that many have regarding the idea that biomarkers are not effective, and misses the fact that he is using biomarkers everyday for C Reactive Protein, Cholesterol etc. The neurotransmitter findings are beyond ‘belief’ and have merit, are useful, not diagnostic, and are helping people, so why not use them?

        Sounds like you are rethinking stimulants – good idea, and they can be used, as your doc knows with Intuniv – I have found that often the stim dose can be lowered and just a slight augmentation can turn the tide.
        cp

  • Cristina Lucas

    Hello Dr, I stumbled across your wonderful blog in my Internet search for Intuniv side effects. Found your expertise and comments board helpful with my 6 y/o hyperactive, impulsive son (smart and sweet, but non-stop active!).

    His psychiatrist suggested we try the starter pack over the holidays for one month to see if it helps curb his hyper behavior that gets him in trouble at home and at school. He’s been on it for 2 weeks tomorrow. Below are results to date:

    Week 1 – 1 mg tablets. We saw great improvement in hyper-impulsive behavior. His personality didn’t change, he seemed more focused and told us the medication helped him “be good.” The family noticed how calm and focused he was when they were in town, especially with change and in large groups (where he usually goes bonkers). Downside – he seemed more tired. Fell asleep in the car a lot. Not too troublesome.

    Week 2 – he has one more 2 mg tablet to finish up tomorrow, then we have an RX for a 2 week supply of this dosage due to his weight requirement.

    Here’s my concern — All was well until tonight. He was on the floor playing and jumped up in severe head pain. He told me he had a terrible headache “all over his head,” a strong stomach ache and felt like vomiting. He never has these issues so seemed to be in a panic about it. It really has me worried. I took his temp, it was 95. No fever. He ate normal, had normal bowel movements and is not dehydrated. Makes me wonder if I should quit the medication all together … what do you think?

    Note — He was recently on 5 mg of Adderall. It helped some but he crashed hard when it wore off. He also had significant decrease in appetite and moodiness. He also took Ritalin and it didn’t work for him.

    Thanks in advance for your professional input!

    Sincerely,
    Cristina Lucas

    • http://www.CorePsychBlog.com Dr Charles Parker

      Christina,
      Crashing happens more often with Adderall [especially IR], – you didn’t specify if it was XR, which has less drop in the PM. Appetite issues can occur with any of the stimulant medications, since you are new to CorePsych Blog Search: ‘breakfast’ for more details. When any one says ‘it didn’t work’ I always dig in further to see if the dose was adjusted accordingly all spelled out if you search: DOE here.

      While headaches and nausea are listed in side effects, I would pay more attention to the Top of the Window with Intuniv Dosing at this other CorePsych Blog Post. Bottom line: he appeared to be having some side effects on the 1 mg, my suggestion to consider with your medical team: go even more slowly, don’t advance until that first tiredness effect has diminished, then advance as indicated. If you notice comments here and on the other dosing post most are having trouble simply going to fast relative to the side effects of that first dose.

      My take at this moment: it’s not Intuniv, it’s the dosing strategy moving too fast.
      cp

      • Cristina Lucas

        Thanks for your response, Dr. Parker. To answer your question — my son was on 10 mg generic amphetamine for a bit. While on it, he was moody and hypersensitive so his psychiatrist lowered the dosage to 5 mg. It worked for awhile (improved control), but eventually had him crashing hard. In short, everyone knew when it wore off. It was obvious by his radical change in behavior later in the evenings. My guess is that it wasn’t an extended release version of Adderall, but I honestly don’t know.

        I will check out your suggested search areas on the CorePsych Blog. What a valuable resource you offer! I plan to add your Web page to my favorites.

        Re: Intuniv. We went ahead and lowered the dose back down to 1 mg by halving the 2 mg pills. Did it yesterday and heard no complaints of headache, tummy aches or nausea. I wonder if it was because of the lowered dosage. We’ll see how he progresses with this dose for the month his dr recommended. One final question – is it ok to give Motrin for a headache on Intuniv? If he gets another bad headache I want to help him, but am wary of adverse reactions.

        Thanks again for all you do. Happy New Year.

        Cristina

        • http://www.CorePsychBlog.com Dr Charles Parker

          Cristina -
          No problem with Motrin [which blocks UGT2B7], not involved with Intuniv metabolism.

          The Adderall XR is capsule, the IR is tablet. If he was on the tablet, as it sounds like he was, the drop in the PM from only an AM dose will almost always become problematic.
          Thanks, sounds like you and your doc are on it!
          cp

          • Cristina Lucas

            Oh good. Glad to hear Motrin is ok to take on Intuniv. Thanks for confirming, Dr. Parker.

            The Adderall is in tablet form so is the IR version. Makes sense now why he crashed in the evenings on it. Not a good mix for him or anyone in the house. I’m hoping Intuniv is the right med for our little guy, especially in reading some of the good comments on this board. We’ll soon find out. Thanks again! ~Cristina

    • http://www.ADHDRollerCoaster.com Gina Pera

      Hi Cristina,

      Congrats for finding Dr. Parker’s blog — it’s the best source on the Internet (or really anywhere) for this rare blend of cutting-edge information on medications, metabolic issues, neurotransmitter precursors and much much more.

      It sounds like your boy might have been taking a generic — which can add its own set of complications.

      You might be interested in the blog post I wrote on generic medications recently (as well as its references to a news article and a woefully misinformed conclusion by Consumer Reports on medications for ADHD).

      http://adhdrollercoaster.org/adhd-medication/update-on-generic-rx-approach-with-caution/

      Best,
      Gina Pera, author
      Is It You, Me, or Adult A.D.D.?

      • http://www.CorePsychBlog.com Dr Charles Parker

        Gina,
        Thanks so much for your comment, it’s always reassuring to find others concerned about the same issues, and that can take that concern and those issues into informed, experienced observations that have street applications. I strongly recommend that readers here not only read this post by Gina, but be sure to hook up with her regular blog posts. Gina provides a significant voice of reason in a sea of folk who seem to either worry what pharma will think, or academia will think, but just don’t get down to what the public needs to know to get the job done. Reading Gina on ADHD [four National Book Awards] will provide a voice of reason and experience, – as she has been listening and researching these matters for years. Then she takes the time to regularly report the unvarnished observations in her book and blog posts. Feedback loops are her specialty.
        cp

  • Denise

    Hi Dr. Parker,

    We have corresponded before. My son is the one with high glutamate levels on his NT tests. The Doc moved him upto 3mg from 2 mg of Intuniv. He’s been on the new dose for about a week and a half. Still no improvement. The Doc wants to try Strattera next, I think part of the reason is that he knows I’m nervous about stimulants. I noticed that you are not a fan of Strattera. I searched your blog to see if you had written anything as to why, and was unable to find it. Would you mind sharing why? My son is only about 68 pounds. Wondering if we should try 4mg Intuniv, or just give up on Intuniv…

    Thanks!

    Denise

    • http://www.CorePsychBlog.com Dr Charles Parker

      Denise,
      Everyday in the office I am searching for efficacy and predictability, and always start with the best on both counts. Strattera, while not a stimulant, often just does not turn the ADHD tide, – and, moreover, often brings an unpredictable side effect profile. I had one girl fall asleep in the girls bathroom! They thot she had run away, called the police, and, much later, found her snoozing on the cold tile bathroom floor. Yes, that is only one case, but tiredness and agitation do occur, so watch if you and your team go that Strattera route.

      Most importantly: It just doesn’t do the job as well – and we often have trouble dialing it in effectively with vague parameters of effectiveness. I have heard so often: ‘I took it and didn’t feel anything.’ The stimulants can have their own problems but are safe, efficacious, and predictable. I just don’t have problems with folks who are cooperative, unless they do have NT issues – picky eater, IBS, constipation, metabolic challenges.

      Having said that, just met a patient yesterday briefly in the hall, an adult woman, refractory to my favorite stimulants, and she was raving delightfully about Strattera’s ability to help her focus ‘so much better.’ About 5% of folks just don’t work with the stimulants, [and this finding is confirmed by many colleagues across the USA with whom I have had this conversation], and that crew seems to be the crew that responds best to the Strattera – thus it becomes the fall back choice – absent good NT info.

      On the NT side: Look at the guys Histamine for sure! I have seen so many, even with a Histamine at 21 that test positive on the food sensitivity panel, and straighten out when the immune challenges are corrected. Stimulants often don’t work as the excitatory/reactive Histamine crowd have taken over, and targeted amino acids simply don’t work on a rusty bowel – they simply aren’t metabolized.

      And I would stay for a complete trial on the Intuniv up to 4 mg, if you aren’t having any side effects.
      Please keep us posted-
      cp

  • http://medfinder.com Dr. Bill Simons

    What is the cost of Intuniv? And is there any preliminary evidence it works in adults or any theories whether adults would benefit. Also, short acting cheap form of the drug peaks 2.5 hours after oral dose with antihypertensive effects persisting 24 hours. I guess I am asking if Guanfacine ER is really necessary or is plain guanfacine just as good (other than being a little more like to cause side effects.
    I have ADD and hypertension, so this might take the place of another med. Thanks, Bill

    • http://www.CorePsychBlog.com Dr Charles Parker

      Bill,
      Interestingly, the Intuniv does appear to act as a significantly different, more predictable, medication with fewer side effects. In conversations with researchers who have used IR guanfacine far more than I, even before the Intuniv was available, they all agreed that it surprised them as well. The had expected less than they got in terms of correcting both the attention and the irritability, as I mentioned in one of these Intuniv posts, even through the next AM [fitting with your 24 hr notes on the hypertension].

      Sorry Bill, I should know, but don’t, the $ on the Intuniv – so much varies, as you know, with each managed care plan. Some simply won’t pay for it because it’s new – and some over there are way behind on the education curve – but don’t get me started.

      I have had some surprising turnarounds in my office, even at the lower doses, and am continuing to find the formula for individualized titration predictability. For now am goint with the suggestions from Shire, have had no big problems, and see more in these questions here than I have seen in my office.

      Hope this helps, please keep us posted… and no, – no adult studies out yet, but the anecdotal, both from colleagues and my office medical team, is that it has worked well, with the usual cautionary notes about not mixing HBP meds.
      cp

  • Carrie

    My son is 8 years old. For the last 3 years we have had so much trouble with him both at home and at school. He is OCD with symptoms of ODD, verbal and motor tics, generalized anxiety, extreme impulsivity, and many other symptoms of ADD. He has been fully tested and has primary trouble with working memory. We have tried everything in this time: diets of all kinds, omega-3 fatty acids, behavioral therapy, etc. in a “natural” attempt to help him. He is extrememly bright, creative, and very sweet until he gets frustrated or agitated, which was constant daily occurence. His anxiety at school or any group setting such as soccer or parties was horrible to see. He has been suspended from school three times for serious aggression (kicking, biting, scratching) towards teachers and was not capable of finishing his daily work at his Montessori school. We were on a road to expulsion and had been asked by both the school counselor and our personal therapist to go to a child psychiatrist to test for bipolar or even childhood schizophrenia. We started Strattera about 8 months ago and saw a little improvement in his mornings at school but nothing to shout from the rooftops about.

    Then we tried Intuniv on the advice of our pediatric behavioral neurologist (who by the way is wonderful and thought the theories of bipolar or schizophrenia were ridiculous) . The change in our son’s behavior has been astounding, unbelievable, amazing, and wonderful. NOW I want to shout from the rooftops. For 3 weeks now he has finally been calm, happy, and relaxed at school and at home. He no longer argues with us, his teachers, or his little sister. He is pleasant and sweet – the boy I always knew he was underneath all the symptoms that seemed so beyond his control. He walks around with a smile on his face and seems so steady. His teachers report that he finished ALL his work every day during the last 2 weeks of school (in 3 YEARS he has only ever finished his daily work about a dozen times) and seems so relaxed. His verbal and motor tics and his stuttering speech have completely disappeared. His handwriting has improved dramatically because he can actually focus on it. Yet he does not seem sedated or “drugged out”. He has energy and humor, and seems just like himself minus all that anxiety. It seems as if his true personality is finally shining through, and everyone has noticed the positive change in him.

    He has had no ill effects from Intuniv save a little drowsiness at around bedtime (not a bad thing!). We will see what the long-term effects are now that he is at 3 mg. We also still go to behavioral therapy and we try every other method we can think of for helping his behavior improve. It just seems like he is able to listen to us (finally!) With the help of Intuniv.

    I am usually uncomfortable giving my children any serious medication and was initially very resistant to the idea. But you have to weigh the risks with the benefits. My son’s benefits? He finally seems completely happy and comfortable in his own skin, is doing his schoolwork, is no longer kicking his teachers, and actually is playing with his classmates at school. The benefits for my family have been huge. My 3-year old daughter is no longer growing up in a house full of screaming, yelling, arguing, and constant frustration and anxiety.

    For our very stressed out family, Intuniv has been nothing short of a miracle. I finally have my sweet son back after 3 painful years of struggle and anxiety.

    We are going to take him off the Stattera when school resumes to see if it is still necessary. I am so hopeful that he will continue to do well on Intuniv and that it won’t suddenly stop working later down the road. It just seems too good to be true.

    So no questions, just wanted to give a positive report from a real family struggling with ADD/OCD.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Carrie-
      High five out to your neurologist, to your family – and to the little guy! Therapy does work much better when executive function works so the child can use the information effectively. As you know, I am no fan of Strattera, but if it is needed you need to know there are no interactions with Intuniv, and therefore no contraindications. If it works, no problem using it.

      Thanks for your input – seems like the classical example of the initial indication. Do watch breakfast – encourage a protein breakfast as you are still working with neurotransmitters. And do watch bowel habits and transit time – metabolic changes can throw off the best laid plans of mice and men.
      cp

    • http://www.ADHDRollerCoaster.com Gina Pera

      Thanks for sharing your story here, Carrie.

      So much Internet chatter deplores parents who “medicate” their children for the sole purpose of “controlling them” or making them “sit still at school.” The chatterers simply do not understand that many of these children are deeply unhappy, and that chronic unhappiness and disruption can destroy the entire family.

      The right medication doesn’t sedate or “drug them out.” It helps them get in touch with their true desires, goals, capabilities, and feelings.

      Congratulations!
      g

      • http://www.CorePsychBlog.com Dr Charles Parker

        Gina,
        You are so kind on the ‘chatterers’ concept. Seems like all folks talk about is what-didn’t-work-correctly. Great to have a pro weigh in, and do look forward to increasing dialogue between health care providers!

        That will have to pass for a wistful New Years Aspiration…
        cp

  • Cathy

    My 8 yr old son was diagnosed with ADHD last spring. We started on Focalin XR then and it worked great until about a month ago. I was reluctant to give more stimulant (he was on 5mg twice a day) but we tried 10mg in the a.m. and 5 mg later in the day with no real change. (as an aside, I don’t know how they call this an XR – once a day dosing never worked) Our MD suggested Intuniv and we tried it. We started with 1 mg for 2 weeks with no real change – a little sleepier it seemed but that’s it. We moved to 2mg and wow – someone stole my son. Not just tired – no joy, no fun. Things that made him happy didn’t and he had no interest in life in general. I refused to add a med to combat the symptoms of the first (as depression had NEVER been an issue) and we stopped the Intuniv. He’s back to himself but we don’t have a good plan on where to go from here. I said from the beginning I would not use meds that changed his basic personality so Intuniv does not seem to be the drug for us. At home the Focalin helps in all areas and he seems ok. At school he is impulsive, “always moving” and silly. Of course we are on break right now and he’s doing well even when I have made do some schoolwork just to keep him into it. I’m a little lost right now as to what our next move will be.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Cathy,
      Do take a look at Gina’s comment on this post, as it does sum up my response to this conundrum: Why not a more effective stimulant, titrated precisely so that it covers the entire day? My favorite, as you will know if you visit CorePsych Blog much, is Vyvanse. It has the benefit of working predictably – if started slowly and increased carefully. See this posting on Vyvanse dosage from about 6 mos ago. For more careful titration strategies on the front end do see the details on the post over a year ago on the Vyvanse Water Titration here as well.

      A further point that appears to regularly enter the discussion on those with challenging responses to any ADHD meds: watch for metabolism issues – outlined in my white paper on the subject, downloaded at this CorePsych Blog page. The absolutely most frequent problem with any challenges on these quite predictable medications: speed of metabolism, drug interactions, breakfast and protein, and sleep, all documented here – just search these terms and they all come up.
      Best of luck with your guy,
      cp

  • Sandra Prehoda

    Brandy,
    As I read your note to Dr. Parker, it seems like the mirror image of my daughter who is 8 years old. I definitely think you should share all with your doctor. If it helps any, I will share what is so far working for us. We increased my daughters medication very slow just as you are doing. With the 1mg she was not quite herself, cranky and irritable, but I immediately saw a difference in school work and at home. Turned out she had strep throat and H1N1, so after the two weeks, the doctor recommended she go up to 2Mg. When she went up to two Mg. I felt exactly like you. It is so scary to see your child like that especially if they are usually silly and energetic as our children seem to be. After about 12 days, she slowly started to perk up… looked like my kid was back to herself. The next time we saw our doctor she placed her on Prozac, but at my request, (as we were adding another med) we kept her at 2 mg. for a month instead of two weeks. After two weeks on both Intuniv and Prozac., her doctor increased the Intuniv to 3 mg. Well, you can read the results below…not a good reaction. Please be sure to read Dr. Parkers advice about dirty meds. We took Dr. Parker’s advice and stopped the Prozac immediately. She was still very sleepy and began to seem depressed. Not sure what was going on- Dr. Parker could tell you better. Don’t know if she was having withdraw from Prozac or if she needs an anti-depressant as well as Intuniv. My (Mamma bear hunch:) was that 3mg. was too high a dose for her after the accumulation of medicine due to Prozac. With Christmas around the corner, I made a choice, along with her doctor, to back her back down to 2mg. of Intuniv. Today she is more herself than she’s been in a few weeks. It does seem to take time for my daughter to adjust to each increase in the Intuniv, but it is definily helping her ADD. I realize that I’m not qualified to offer any advice, I’m just sharing my experience as I see the similarities in our situations. Best wishes to all for Happy Holidays. Hang in there, Dr. Parker and others are offering their best advice, keep watching and listening to the experts…and keep the faith!
    Sandy

    • http://www.CorePsychBlog.com Dr Charles Parker

      Sandra,
      Thanks for weighing in, and right on with the Prozac. Often the reaction doesn’t occur right off the bat, but does show over weeks or months – so simply being alert can avert downstream problems. Time is the factor: with the passage of time it seems like interactions are not the problem – but some other unexplained something is the culprit. -And you wind up guessing repeatedly. Time will show that interactions with Prozac are easily corrected.

      No withdrawal from Prozac, as it only shows discontinuation syndrome very rarely, and only after being on it for an extended period. She very well may need an antidepressant, check with your doc for the one clean on 2D6. Remember, off of Prozac you will always have a better, less complicated, less modified set of symptoms to evaluate.

      Please do keep us posted – it will be interesting to see how she is over the Holidays-
      cp

  • http://brandys1@comcast.net Brandy Smith

    Glad to find this blog. My daughter is 6yrs old, weighs 39 lbs. We have had behavior issues since she was about 3 yrs old. Teachers used the usual “impulsive, immature, talks out of turn, talks excessively, disrupts class, always trying to be funny…” I could paper the walls with the notes. Academically – she is well above average. The pediatrician really did not want to address these problems b/c of her low weight and her academics are not suffering. So, we decided to a psychiatrist for help. In the meantime, we had an IQ test done to see what we were dealing with. She scored in the top 2% for her age group in all areas except the Working Memory Index (where she received a very low 25%!!). The diagnostician said we have a gifted child, 130 IQ, but with definite Attention weaknesses. Psychiatrist said it is the “hyper” kind and prescribed Intunive as our first attempt at help. 1 mg for one month to start. Week one (sleep constantly). Week two we saw some improvement in impulse control and excessive talking. Weeks three and four – back to where we were before (teachers claimed to see no improvement with self control). So, three days ago we went to the 2mg stage. She is even more tired. Fell asleep in a class twice today. I checked her pulse and it was 62 beats per minute last night and again tonight. She is pale and looks so tired. I feel like I am harming her. I called our doc and she is offering a switch to Strattera, and said 62 bpm is low. I don’t know how I feel about Strattera. I think it will be more of the same. How long should we wait to see if the extreme tiredness goes away? I want to stop immediately (mama bear). My husband thinks we should wait the full 7 days to be sure. At this rate she will sleep through Christmas.

    I just want to help her get more self control but not knock her out in the process. Would appreciate any advice.

    Worried.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Brandy,
      Best to report these findings to your doc and pass the ball to her. It does appear that you are moving reasonably and correctly, as from the first titration she took a considerable time to reach the expected plateau. She could be simply slow to metabolize for a variety of reasons, – suggestions regarding the changes in burn rate covered in some of these other questions. – Agree with the fact that ‘knocking her out’ seems quite counterproductive. As for me, I’m on the conservative side, and always err on the side of too little.

      Will be interested in your keeping us posted please.
      cp

    • http://www.ADHDRollerCoaster.com Gina Pera

      Not-Dr-Parker here, Brandy, but I just have to ask why the doc has not mentioned a stimulant. They are the first-line treatment for ADHD, and your child doesn’t seem to have any contraindicative issues. If it were my child, I would surely consider a stimulant before Strattera.

      As for the tiredness, I’ve often seen adults with ADHD who are tired and sleep a lot after starting treatment. For many of them, they are “paying off a sleep debt” after years of getting insufficient sleep. After a while, they normalize. So, if your child has never gotten good sleep, perhaps that is the reason. Or perhaps it’s that Intuniv is not the right medication for her.

      I encourage you to keep reading through Dr. Parker’s site (and listen to the radiocasts, etc.). And especially look at some of the dietary issues he writes about. If she’s a cereal-and-milk kid in the morning, for example, you might want to re-think that.

      • http://www.CorePsychBlog.com Dr Charles Parker

        Gina and Brandy,
        Thanks for weighing in on this one, completely agree with your entire perspective. So often the stimulants are overlooked, just simply trying to stay away from them, – when they are first line treatment for ADHD. I completely agree with the suggestion of stimulant before Strattera as well, and only use Strattera as an absolute last choice.

        The common other denominator: metabolic issues with the diet will significantly interfere with success on any level… then you have to do the food sensitivities test.

        As Gina so correctly observes: if it proves to be the wrong medicine change it. If she has metabolic issues [appetite, picky eater, bowel] be prepared, very likely nothing will work as expected.
        cp

  • j

    I have an 8 yr old son with ADD/ADHD. I also have ADD and so does my husband. We both take med for it so we know it helps. I am an artist and my husband is a philosopher. Needless to say we are a creative family. My son is very creative but he started having problems concentrating in school. He would over think what he was trying to learn. Asking so many questions and getting frustrated with the basic answers. It became a problem in school. He was very analytical when learning to read he focused on the “reading rules” but when there was an exception he became frustrated. Reading and writing has become a challenge. According to his teachers and head of school, his comprehension and understanding of subject matter is extremely high for his age. In spite of his reading ability. He is in the 2nd grade and reads on a 2nd grade level but at his school most 2nd graders read on average 2 grade levels ahead.
    We were advised to try Focalin 5mg to help. He has made a lot of improvement. However it makes him anxious, loss of creativity, and he has lost weight. He has celiac disease and the weight loss is a problem. we have been on a gluten free diet for 6 yrs.
    He has bilateral amblyopia ,diagnosed at 3 with +1100/20. now his vision is +650/20. He seams to be experiencing vision disturbances and twitches in eye. We had his eyes checked and all is going well.
    He is a happy child never had any anger issues, has a lot of friends and gets along well with peers. He makes friends easily. According to his last school report he has a strong ability to defuse conflict and suggest a solution. He has respect for adults. We just have a problem with daydreaming following directions, talking asking questions, hyper focusing on a rule or subject, doing tasks in a timely manner– he gets distracted. Both at home and school. It does cause a problem, especially when we need to do something quickly.
    Would Intuive be good for us rather than Focalin?

    • http://www.CorePsychBlog.com Dr Charles Parker

      j,
      Sorry – Answered this question over at the Intuniv Dosing post here.
      cp

  • Christel Johnson

    I am wondering about the effectiveness of Intuniv in adults and have not been able to find any information on it. Are the side effects the same in adults as children? It has been recommended for me to use but I have had the most positive changes on Adderall XR. I realize that as I age the Adderall is harder on my body but being able to function at work and get along day to day is also important. My impulsiveness is decreased, my attention span is longer and I am able to somewhat control my hyperfocus to my benefit. I do seem to metabolize it quickly with a slump after about 6 hours so I do take it twice daily. I am concerned about changing medications when this seems to work the best so far and I am also concerned about the side effects. Also, can Intuniv be taken as an adjuct to the Adderall XR so that I might be able to decrease my dosage to once daily? Is there any benefit to using both the Intuniv and stimulants together?
    Thank you so much for your time.
    CJ

    • http://www.CorePsychBlog.com Dr Charles Parker

      Chirstel,
      Adult indications are under review right now, so no specific recommendations have arrived from the company about use with adults. My sense of matters: Tenex, though significantly different, has been approved for adults for years, so there should be no problem. I suspect the very same pattern of low and slow starting for adults will become the standard as it was when going from the child studies with Vyvanse to adult indications.

      Best bet, just remain aware of the dosage, the drug interactions and indications as documented in these other posts. – And, yes, preliminary, recent studies show that it can be used effectively with Adderall and MPH compounds. There are some indications that they can work well together. I think that one will be determined in the office by the doc and the patient reviewing.
      cp

  • Cathy Moir

    Dr. Parker,

    I have just stumbled across you and this site in my research into Intuniv. My son just recently turned 8 and was diagnosed with ADHD this past spring. As I continually read about ADHD kids Luke seems wise beyond his years, is very bright when it comes to building things or math and picks things up quickly when he is receiving instruction one on one or in a very small group, but he struggles in school generally. Long story short, we started with a central auditory processing disorder diagnosis when he was six as his primary issue seemed to be language both receptive and expressive. An exam with an audiologist confirmed a fairly significant CAPD at the time. As he progressed in school it was obvious that ADHD was also a large part of his problems as impulsivity, restlessness, inability to attend, and defiance increased as he got older. We saw a neurologist who, after an EEG, perscribed Focalin XR. This worked like MAGIC, at first. We started with 5mg and after about a month moved up to 10mg. He was able to focus, concentrate and made great strides in school. His language issues even seemed to improve. Now it seems the Focalin is either failing him or is the wrong drug. His ability to focus has tanked, he has become very impulsive (throwing things, slamming things on his desk) and is increasingly defiant (refuses to do work, follow directions). While other times he seems spaced out and at home sometimes too compliant and sometimes melencholy for no reason. With age it seems his receptive language abilities are about right at developmental level, but his expressive abilities are still below, which of course is leading to some frustration on his part especially when he is supposed to expressing himself through writing. We were seen by the NP in the neurologist’s office today and she suggested Intuniv. From what I’m reading it sounds like it may work for Luke but she has suggested we stay on the Focalin while we start the Intuniv? Does that make sense to you? (She mentioned d/c’ing the Focalin eventually)

    Second in one of the posts above you mentioned something about “immune dysfunction, bowel challenges and is-he-a-picky-eater”. While Luke is rarely sick, I don’t think he has a solid BM in his life (not watery, but always very, very soft) and he would live on Mac and cheese, peanut butter and jelly and chips if I’d let him. He NEVER willingly tries anything new and is indeed very picky about what he eats. As all of this is very new to me can you shed some light on what this may have to do with anything and what to do about it – or point me to the best place to read about it? We have tried adjusting his diet, etc. in the past but because he is so picky it is very difficult to do.

    One additional thing that the NP this a.m. more or less ignored – prior to starting meds Luke would wake up in the middle of the night crying and saying his head hurt. He’d be up 30 min. or more, would eventually throw up and then go back to sleep. In the morning you’d never know anything happened. This would happen about once a month from the time he was about 6. I only recall it happening once during the day at school. Once we started Focalin those incidents ceased completely. We had our first return of that 2 nights ago. Any idea what that’s all about? Initially the neurologist said it was “interesting” but had little else to say about it.

    Thanks so much,
    Cathy

    • http://www.CorePsychBlog.com Dr Charles Parker

      Cathy,
      Interesting how just a bit of info can take you down different paths – and without a compass it can be disconcerting out there in the woods.

      No problem taking the Focalin as suggested with the Intuniv – take a few weeks to reach the correct dose with Intuniv as spelled out in this more recent Intuniv post.

      The most telling challenges are in the last two paragraphs of your note: Picky eater, immune dysfunction, bowel issues, and diet are all the bellwether for challenging times if not completely identified and corrected. I would wager he is low on the excitatory neurotransmitters, and that even the excellent Intuniv, while it may work for awhile, will likely meet the same fate as the Focalin – quits working.

      He is a very good candidate for neurotransmitter testing and the last items you mentioned with sleep and migraine are quite likely related. Best bet: measure the biomarkers, and move forward with specific interventions as soon as reasonable.
      cp

  • http://www.corepsychblog.com/2009/07/intuniv-for-adhd-understanding-tenex-guanfacine-and-alpha-2/ Sandy

    Dr. Parker,
    It is such a relief to find some information from other parents and doctors who are trying Intuniv as it is such a new medication. My daughter has been taking it for about 6 weeks now. We went very slow on dosing just as you have recommended, and it is working wonders. I will say that she has become more irritable and extremely sleepy. I believe that as she adjusts to the dosage that the irritability goes away. However, we have just increased her dosage to 3mg, so she is still adjusting to the extreme sleepiness.

    The doctor we are seeing put her on Prozac for anxiety, but have I read correctly that you would not recommend Prozac with Intuniv? She has been experiencing very strange sleeping patterns. She is either staying awake many hours, going to sleep right away and then waking hours early, or so sleepy she falls asleep around 6PM and sleeps through the night. Considering her sleepiness, the doctor recommended giving her the Intuniv at night and the Prozac in the morning, but this has not been helping. Should we be giving her the Intuniv in the morning despite her sleepiness? Also, would you recommend something other than Prozac for her anxiety.

    THANK YOU so much for your truly caring concern for parents and children working through ADHD. Every Doctor should give such personal and attentive care to their patients. Thanks for sharing your plethora of knowledge!
    Sandy

    • http://www.CorePsychBlog.com Dr Charles Parker

      Sandy,
      Thanks for your kind remarks, and, yes, you read it right: Prozac and Paxil [and Luvox] should not be given with Intuniv. Intuniv is a 3A4 substrate, but not listed on this link [is listed as such in the PI [package insert]. You will see on this first linked list that they left out guanfacine as a 3A4 substrate, but they did cover the bases with the rest of the inhibitors. Also, on the induction side, have to watch Tegretol or Trileptal, as they can both induce Intuniv [cause it to run through to fast requiring higher doses [see the first link], and for those treating bipolar disorder with Intuniv watch for Depakote as a inhibitor as well.

      Your girl is very likely accumulating Intuniv, and is coming out the ‘Top of the Therapeutic Window‘ – with the result that your doc is doing what he/she knows best, changing the dosage time of day to accommodate to the obvious side effect. Great idea if the interaction weren’t the key problem.

      In this case I strong recommend you download and print the interaction link for your doc, and get off that Prozac. What I find so disconcerting in this interaction scenario: Intuniv gets blamed for this weird reaction, and Prozac [and others noted] are the culprits. I have repeatedly seen this kind of problem with AMP products such as Vyvanse and Adderall for years, as many continue along in denial that the CYP 450 system doesn’t require attention – and the fact that dirty drugs can create significant problems with otherwise clean medications that work very well if used correctly. The good meds get blamed as they are new, and the old dirty ones get off, based simply on familiarity! Sounds like a popularity contest, not science.

      Drugs that are clean on both 2D6 and 3A4 are Effexor, Pristiq, Lexapro, Celexa, and Lexapro has recently found an FDA approval down to 12 yo. Irritability and sleepiness should go away – but, without knowing more, I would try her just on Intuniv alone before running another med in there, it might work well as a stand alone.

      Hope this helps,
      cp

      • http://www.corepsychblog.com/2009/07/intuniv-for-adhd-understanding-tenex-guanfacine-and-alpha-2/ Sandy

        Dr. Parker,
        I can not thank you enough for your advice. You confirmed what I felt as a parent may be true. No one knows their child like their own parents, but we can’t just rely on our gut feelings when it comes to the complex issues that some medicines can create. I really loved how the Intuniv was working until the Prozac was given. I will definitely take your advice and speak with my doctor about getting her off the Prozac and staying with the Intuniv on it’s own. You have been the source of comfort I have found in this process. I have searched far and wide for advice about this new drug called Intuniv. My hope is that many more people will run across the information you have provided as so much of the time, as you’ve said, the good meds can get blamed for the dirty works of others. To anyone reading, so far Intuniv has been a definitive YES for my child! Dr. Parker, again, your advice has been worth more than I can say… Thank You, Thank You, Thank You!!!
        Oh, One last question, would you recommend weaning her off the Prozac (fluoxetine) slowly? She has been taking a 20 mg capsule daily for about a week now.
        Sandy

        • http://www.CorePsychBlog.com Dr Charles Parker

          Sandy,
          Thanks so much, glad we are on the same page. – Will be sending out another post on Intuniv drug interactions soon using your comments – your questions have been most helpful.

          No wean necessary on Prozac, just drop the stuff asap – and get in for the next antidepressant, clean on 2D6.
          cp

          • http://www.corepsychblog.com/2009/07/intuniv-for-adhd-understanding-tenex-guanfacine-and-alpha-2/ Sandy

            Dr. Parker,
            Tears of joy in my eyes- YOU’RE AWSOME!
            Sandy

  • http://adventurestudio.com Kate Scholl

    Hello Dr. Parker -
    Regarding the NT test, which I just mailed back today, are childrens’ tests typically done with a urine sample, and how does medication presently being taken get figured into the results, particularly if one is still in the process of trying to find the right DOE and correct combination of meds for treating comorbid ADHD, ODD and general anxiety? I was just wondering how accurate the tests are for determining possible cause (of disorder) and potential effectiveness of a current treatment. Forgive me for sounding a bit ignorant with regard to the medical testing processes, but I’m trying to improve my understanding of the science. I have a “mother-lion” fear of getting caught in a loop of one pill, then another, to treat the side effects of the previous… ad infinitum. Regardless of my fears, I completely support pharmacology especially when I am able to ask and learn – knowledge is power. That said, I think I speak for most parents, especially those of us with a more complex ADHD diagnosis, when I say it is scary to give a young child medication.

    Quick update: Jack is on night 3 of 2mg of Intuniv and we’ve had some behavior regression “meltdowns”, which seems to be related to how tired and/or fatigued he is. The 10mg of Metadate he takes in the morning are not as effective now. While I’m waiting to get the NT results and consult with you, I’m trying to follow your advice and find the “window”, but I’m a bit confused. I’m going to talk to Jack’s regular doc tomorrow and I just want to be clear in my understanding of the window. If I’ve done my homework, we would increase the Metadate CD to 20mg and hang in for the week on the Intuniv and then go back to 1mg if no improvement is seen. Finally, we give Celexa for Jack’s anxiety – 20 mgs every night. He has done well on the celexa, but if/when the Intuniv begins to really take effect, at what point do you typically cut back the dose on the other drugs, or do you? I’ve read of Intuniv’s success as a monotherapy on your site, but that sounds almost too good to be true? If you could connect the dots, I would be most grateful.

    As for me, after a very long day of trying to keep too many plates in the air, I’m ready for a nice glass of wine and some good fiction!

    Kindly,

    Kate

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kate,
      Running to a meeting in Atlanta today – short note: I don’t know if we will be talking but hope to as all the subtle nuances of these questions will take the full hour of conversation.

      Several issues: Sounds like he is taking the Intuniv in the PM as well as the Celexa – both are usually in the AM and sounds like the Metadate is not dialed in correctly either. With that kind of background challenge it is almost impossible to make a declarative speculative pronouncement on the NT findings until I have a chance to review every detail.

      Sorry can’t be more helpful, look forward to hearing what your doc says.
      cp

  • cally

    My 12 year old is on Concerta 63 mg and has been on Concerta for about 28 months (with a gradually increasing dosage as she has grown a lot), with a month off this summer to trial Vyvanse (awful experience of zombi-girl and depression.) We are not totally happy with the Concerta, namely because of the AWFUL morning and evening experiences we have—she can be really aggressive and it is a real problem when she has sleepovers at a friend’s or activities (band, parties, etc) later in the evenings and she’s left “high and dry” as the drug is no longer working. She does well at school however, and is on the honor roll, but evening homework time is HORRIBLE.

    She was given a SPECT scan in August of 2009 from one of Dr Amen’s associates and the scans were read out of Dr Amen’s clinic. She was found to have “ring of fire” adhd. We started on Lamictal with limited success (stopped some obsessive behaviors) but has done little to nothing for the explosive nature of her personality, even at 150 mg.

    Anxiety is also a component and just this week I had an appt with our psychiatrist and a small (10 mg target dose) of Celexa was added. Needless to say, the growing list of prescription meds is a concern to me.

    I’ve been following the whole Intuniv development process for the last several months online and just stumbled on this blog and one other where girls with ring of fire adhd are mentioned specifically. Both seem to be having phenomenal results with Intuniv or guanfacine. I called my daughter’s psychiatrist just this morning about trialing Intuniv over the winter holidays. I just got a call back, and he is sending us a starter pack!

    Do you think it is even remotely possible, if she has a positive response to the Intuniv, to “eventually” get her off of the Celexa, first and possibly even the Lamictal? Is the Intuniv THAT good at taking care of the issues, in your opinion/experience? Clearly I will do what works best, but do I have any reason to hope??

    Thank you for your time.

    Cally in Texas

    • http://www.CorePsychBlog.com Dr Charles Parker

      Cally,
      Thanks for your note, busy PM, but will get off a quick reply:

      Having worked with Amen for many years [4] in his DC office I can attest to the significant contribution Amen has made with SPECT and the addition of metabolic brain evidence [SPECT = Regional Cerebral Blood Flow] for complicated presentations. What SPECT does not show, and Amen completely agrees with this point, is what is causing the underlying ‘Ring of Fire’ [a regrettably evocative and non-scientific term with very little in it that endears Amen to the neuroimaging community].

      The result of that unhappy circumstance is that one can see suggested other interventions, but the clinical intervention process is still completely hung upon the evaluator/psychiatrist in the office with you at that moment. I have often seen ‘Ring of Fire’ associated with significant moods, and agree that the findings do imply major mood dysregulation, but the fundamental question nevertheless persists: What is causing that specific SPECT finding – and even more importantly, what are the many causes of that diffuse cortical hyperperfusion? Bipolar is not a cause, it is a result, an appearance from the outside looking in. DSM-4 does not correlate with SPECT, DSM-4 is static and descriptive, SPECT is functional and explicitly introduces the variables of measurable time and specific context.

      Intuniv does hold interesting promise, but, quite frankly, it is too early in that game to stand and shout the positive possibilities from the rooftops – since we simply have not traveled enough miles down the road together. Having said that, it does look very promising, and having done multiple presentations with many physicians over the past months I can report that the response from many has been surprisingly good. The research does look very good.

      Finally, there is much reason to hope. I would expect that your daughter might even be better with the Celexa. More evidence is available, documented in other comments here, so rest reassured there are answers out there for your girl. SPECT is but one emerging view of the functional brain.
      Best wishes, please stay in contact and let us know how matters turn out.
      cp

      • http://www.ADHDRollerCoaster.com Gina Pera

        Dr. P — I’ve been meaning to ask you. Is the Neuroscience testing applicable to children and teens? I’ve heard that the baseline group was composed of 20-30-year olds.

        It would be great if parents had a tool to help target a child’s needs without so much trial and error.

        Here is a linkL http://www.corepsychblog.com/244/

        Folks, my husband and I did the testing recently, and I was highly impressed. My local physician, who is extremely knowledgeable, likes that test, too.

        Moreover, we did it from home (you just spit in tubes and mail it in…..Dr. Parker forwards the results to you in a PDF and you discuss by phone). I’d always been intrigued by supplementing with amino acids but until this test, it seemed like too much a hit-or-miss process. They’re working tremendously well for my husband, if less so for me. Then again, I think I just need some rest! :-)

        Gina

        • http://www.CorePsychBlog.com Dr Charles Parker

          Gina,

          Yes, the testing is quite useful in complex issues for children and adolescents, as that age range often has even more difficulty identifying chronic underlying issues even as obvious as fatigue.

          I recently worked up and ASD child, more on the Asperger’s side, and soon after starting he improved eye contact, became more settled and suddenly asked his father to go fishing! A landmark first for this disconnected child.

          Looking forward to seeing what your progress and problems are… exhaustion can definitely take longer to come around!

          Thanks for your kind remarks, and very pleased to hear that his nibs is moving along! Talk soon!
          cp

      • cally

        Thank you so much for your kind words and cautious encouragement. I am really hoping this helps. I pulled out some 3 year old NeuroScience test results and noted that her glutamate, GABA and PEA were all elevated, serotonin was low, etc. Poor kid. We’d tried the products recommended at the time, without success. My girl is a tough nut. We have had her on a good multi vite and oils since age 3, so that is a constant.

        I’m looking forward to the elaborations on the use of Intuniv along with the Concerta. I want to know all of the options for discussion as needed with our doctor.

        Thanks again for your help.

        Cally

        • http://www.CorePsychBlog.com Dr Charles Parker

          Cally,
          In second opinions with NS I frequently see that many limit their corrective experience to only what the initial NS findings suggest from the lab. They often don’t know precisely how to measure and evaluate the response to the interventions, just as many are missing the mark completely with basic stimulant meds. With NS the clinical results often take more time, are more subtle, and without an awareness of the subtlety of the change and an appreciation of what to do next, the medical team prematurely calls it a day.

          Interestingly, another oversight: the frequently missed points regarding potential other interactions with immune & hormone dysregulations. I just saw a ‘hopeless case’ today referred from TX after ‘counterproductive’ SPECT imaging. SPECT showed a hypometabolic brain with abundant diffuse hypoperfusion, and, as is often the case, he was left with the brain injury diagnosis, after absolutely no history of brain injury. You don’t have to have ‘brain injury’ to have punched out images with cerebral cortical scalloping and large cold areas.

          The patient suffers from an abundance of chronic metabolic issues, with almost every NT completely in the tank. After about 1 mo of working with neurotransmitter precursors the stimulant and antidepressant are starting to kick in, and he can actually move around his home. He is completely disabled with significant adrenal fatigue, and without specific attention to his adrenals we would simply be shooting well intended blanks.

          I just added Balance D, as his DOPAC [the primary breakdown product from dopamine] was completely in the tank, showing he had simply no DA reserve. He is remarkably better even without this specific next intervention. – These days we often see these results, and this type of dramatic change simply cannot be classified as not anecdotal.

          Made my day, hope it helps yours,
          cp

  • http://www.ADHDRollerCoaster.com Gina Pera

    Hi folks,

    Dr. Parker is the rare physician who not only deeply understands these complex issues but also is incredibly generous in sharing this understanding.

    I encourage you to sign up for his free e-book (“Predictable Solutions For The 10 Most Common Challenges With ADHD Medications”). You’ll find many explanations and strategies you won’t find elsewhere and that are critical for helping yourself or your family member “get the meds right.” It seems that many people (and their physicians) keep trying new medications before properly dosing (and perhaps combining) the medication that might prove best.

    Here’s the link: http://www.corepsychblog.com/adhdbook/

    Gina Pera, author
    Is It You, Me, or Adult A.D.D.?

    • http://www.CorePsychBlog.com Dr Charles Parker

      Thanks so much Gina!
      I do hope folks do go over and check that white paper out. It has a considerable number of details in there for 20 pgs – I’m adding so much more to the book. I have to stop this writing and just get this edition out!

      And whilst you are at it friends, do take a look at Gina’s book: Is it You, BE, or Adult ADD? it has won many [was it 4, or 6?] book awards, – simply because Gina is so completely authentic and candid, and so irresistibly fresh in her approach to the complexity of problems in relationships challenged by one or two with ADHD.

      And PS, Gina will be speaking at the ADD Resources conference in Seattle 11-14, this next weekend. Wish i could be there!
      cp

      • http://www.ADHDRollerCoaster.com Gina Pera

        Thanks, Dr. P. Actually, the ADD Resources conference was in November, and I thoroughly enjoyed myself. Beautiful city and wonderfully responsive and attentive audiences!

        • http://www.CorePsychBlog.com Dr Charles Parker

          Hey G,
          That’s what I get for posting so early in the AM! ;-)
          cp

  • Kimberly

    Dr. Parker,
    I am ecstatic about the wealth of information on your web site, as we are considering a move to Intuniv for our 10-year old son. He was diagnosed with ADHD when he was 5 (almost 6), with his greatest challenges being impulsivity & attentiveness with hyperactivity as well. By age 6, he was experiencing motor & vocal tics that had persisted since age 3. His tics appeared daily although not constantly, but were increasing in variety and frequency. At age 6, he started 36 mg of Concerta. The positive affect on his attentiveness and impulsivity was dramatic. However, his tics became alarming. Our neuropsychologist added Tenex to the mix (.5 mg in the a.m. and .5 mg in p.m.) With the addition of Tenex, he has virtually no tics… Only the occasional “hic” here or there. Tenex has been amazing for this purpose, and that is why I am familiar with it.

    Now, at age 10, my son has taken 45 mg of Concerta for almost 2 years, but we see a decrease in his attention and impulsivity this school year. We considered an increase to 54 mg, but he has a fairly high anxiety level and also suffers from sleeplessness, which (of course) worries him greatly. In speaking with his school team, we discussed the possibility that a non-stimulant ADHD med may alleviate both his anxiety and his sleeplessness. Not surprisingly, our doctor does not have experience with or a great deal of knowledge about Intuniv. However, we hypothesized that if guanfacine “works” for him, perhaps his behavior ALREADY should be “improved” during those first a.m. hours after he takes .5 mg of Tenex. I don’t know if this hypothesis is at all valid. However, I am not sure we see marked improvement in the earlier a.m. versus early afternoon. He clearly becomes less capable by evening, and we occasionally (no more than once a week) give him a 5 mg booster of Focalin at 3:30 when he has evening activities and lessons that require his attention until 8:00 p.m.

    My question is… For a 10-year old child (about 62 lbs) who has already been taking .5 mg of Tenex in a.m. and .5 in the p.m., would we see a big difference with Intuniv? I can’t imagine that a 1 mg dose of Intuniv would do something that we’re not already seeing, but who knows? Do kids his age ever take a 3 or 4 mg dose of Intuniv? I would love for him to give a non-stimulant med a try. But, I am struggling with the idea that he already takes 1 mg of Tenex during the course of the day PLUS Concerta… Might Intuniv be a good alternative? Or, would a look at something like Strattera be better.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kimberly,
      First of all, thanks for your very kind remarks – no matter how you slice it these new meds, and the new science, offer so much hope for the challenges many face. – And the neurophysiology, the deep solutions, while somewhat new and complicated at first, really can be translated for everyday street application. Thanks, it’s a real privilege to find myself in a position to actually have this great info, and for that I thank the pharmaceutical companies, specifically in this case, Shire, who take the time, and invest the actual dollars to educate docs like myself to improve our help for our patients.

      Your boy is an excellent candidate for Intuniv, no doubt. Several key points for your doc, which, if he sees reps, which every doc should do, he will get this next set of info – if he doesn’t these are cautionary notes do prevent surprises. Shire’s research teams have already asked many of these questions:
      1. Intuniv is different than Tenex in that the release makes it a very different drug, with a clinical half life of 24 hr. The evenings and even the next morning are covered for many folks.
      2. Peer reviewed evidence in specific studies show that attention significantly improves, and it is not only for opposition or irritation, even tho it works well for both ADHD symptom pictures.
      3. Important point: Start with 1mg Intuniv the first week and stay with the recommended dosage strategy. No need to rush, and don’t be disappointed with no big change the first week. Only about 20% did well with 1mg/day in the AM. [For others: always start back at 1 mg/day even if your child is already at 2-3mg/day.]
      4. Most kids in the studies with [from 6-17 yo] children and adolescents did best in the 3 and 4 mg dosage range. But the dosage is often dialed in best by watching the weight and using it somewhat as a guide [kids with more weight needed the higher doses - all spelled out for you and your doc specifically in the sample pack]. Unlike stimulant medications the metabolic rate and weight are related with Intuniv, and not so idiosyncratic as with stimulant meds.
      5. Shire has just released as study reviewing Intuniv with AMP and MPH products and they show no untoward effects used together. Your doc can ask his Shire rep for that study, I hope to add it in a post here at CorePsych Blog soon, depending on pharma guidelines.
      6. Intuniv may prove to be sufficient as a stand alone… only time will tell. I would not even consider Strattera – it has been largely a waste of time and money in my office – but it does work as a last result for about 5% of patients. When I am down to that ‘maybe Strattera’ level I would insist on neurotransmitter testing rather than continue to shoot blanks.

      Good luck, does sound promising, and feel free to print this out for your doc if it might be helpful to your medical team,
      cp

      • Kimberly

        Dr. Parker,
        Thank you for the fast & detailed reply. I am intrigued by the study you mention regarding use of MPH products (like Concerta) together with Intuniv. This raises a host of questions, like, can the dosage of Concerta then be reduced over time? Is it worth it to try Intuniv alone, reach some type of (hopeful) improvement and then consider adding Concerta back into the mix? We live in Wilmette, IL (northern suburbs of Chicago). Our last neuropsychologist moved out of the area, and for the last couple of years we have simply been redosing and consulting with our general pediatrician. I am feeling like it’s time we should have a re-eval with a pediatric neuropsych or psychiatrist — hopefully someone with some research knowledge about guanfacine/Intuniv. Do you have any recommendations? (Evanston, Northbrook, Skokie, Glenview, Northfield, etc.)?
        Best regards,
        Kimberly

        • http://www.CorePsychBlog.com Dr Charles Parker

          Sorry Kimberly,
          Don’t know anyone up there yet – will soon be training interested professionals and providing those names on the website.
          cp

  • http://adventurestudio.com Kate Scholl

    Hello,
    Jack just completed the 1st week of Intuniv 1mg and we move up to 2mg tonight. The only side effect thus far, is tiredness and slightly puffy eyes. No real change in temperament, but I’m thinking “no news is good news” at least for Jack, since he has had challenges with medication. I know it can take 6-8 weeks to determine effectiveness, but I was wondering if the fact that he had taken Clonidine for 10 days would change things?

    The good news – he seems to be doing well on the Metadate CD and it does make a difference in his ability to focus and stay on task. However, since he is homeschooling until Jan, I can’t really tell how he’ll do in an actual school setting as this is where his oppositional behavior tends to escalate. Good thing we have a little time before he starts his new school, a Montessori Elementary School with about a 1:10 student/teacher ratio. It is small and “home like” which Jack prefers, so we’re keeping our fingers crossed that the Intuniv helps with his coping skills. I must say, however, that working at home with Jack has been great. (Never thought I would feel that way). Since I run my business from my home office, I can have him in my office during the day. He is sailing through the work, the same work he was struggling with in a traditional school setting (private parochial). In fact, he completes his work so quickly that he has lots of time to pursue his interests in drawing, legos and engaging his imagination – all healthy practices for his active mind.

    The truth be known, I’ll miss him when he returns to school. I’ve seen a whole new side of Jack by having him home while the other children in the neighborhood are at school. There are no competing distractions so the entire energy level is different. I’ve learned much about my son as a result. Regardless of what happens with Jack’s schooling, I’m fortunate to be in a position to choose what works best for Jack and our family. It has been so nice to have a break from teachers and school directors calling me during the day about Jack. Often with a caring, but irritated tone in their voice. If they only knew what we’ve tried so far! To others facing similar challenges, if homeschooling (temporarily) can prevent the total shattering of a child’s self image, then I would find a way to make it happen. There are numerous resources online and in most communities, for families like ours, who occasionally need to take a step back from the “system” and remind ourselves that it’s okay to take a different road and it’s okay to blaze new trails. With the right attitude and the correct medical help, kids with ADHD can grow in acceptance of who they are instead of wishing or trying to be like someone else.

    I’m so happy to have found this site. Since I started this journey with Jack, my instincts about what is accurate (regarding ADHD information) and what is intended to scare and or shame, have become highly attuned. I would recommend this site to anyone in need of helpful information and real support dealing with complex neurological disorders that are treatable, but as many of us know, can be tricky. Dr. Parker, you are a generous guide indeed.

    There’s a line in the movie, “Remains of the Day” where a young student asks Mr. Stephens (Anthony Hopkins), “Why do people read?” and Stephens replies (I’m paraphrasing), “So they don’t have to feel so alone.” That’s why sites like this matter.

    Thanks,

    Kate

    • http://www.CorePsychBlog.com Dr Charles Parker

      Kate,
      Thanks as well for your very kind remarks, it sounds like you and your medical team are moving smartly along. I share your deep appreciation for all those before me who have taken the time to write down the details of what-works-best.

      1. I completely agree with your conservative, relaxed, watch-and-wait attitude – as do the many physician researchers who have reviewed Intuniv with hundreds of children. Their message: Don’t hurry, watch for the specific response, remain informed about side effects, and sail by those markers – and stay in that Therapeutic Window! ;-)
      2. You will likely see results sooner than that: More likely they will occur in week 2, 3, or 4. Watch the top of the window as in the post, but don’t fret if he becomes a bit soporific, as with continued use that side effect can diminish over time. If too soporific, fatigued, or just plain tired, and having trouble coping, simply discuss dropping the dose back 1 mg with your medical team.
      3. On a reassuring note: You, as would any parent, might very find some relief with these next interventions, and won’t have to worry so much about the guy at school and with peers. It’s just great with parents like yourself who can make the extra time and support their kids as you have – when he is 23 he will be thanking you.
      4. You are talking to the right guy when you are talking about ‘the system.’ Systems may work for many, but don’t work for everybody, in school, or in medicine – the real deal is a caring, highly individualized, ‘custom job’ either with parenting or with medical intervention. It can be lonely without great opportunities for dialog such as this – and I am looking forward to providing some means of regular teleseminar meetings and a forum through CorePsych to further enlarge our community communications.

      Thanks for keeping us posted, Kate. This next week will likely see some hint of improvement.
      cp

  • Angi

    Is intuniv at all similar to strattera or ssri’s? Intuniv sounds great for my daughter, but Strattera and zoloft both cause a lot of suicidal ideation. I know that they affect seratonin and norepinephrine, does intuniv do something similar? I really don’t want her to experience those thoughts again.

    • http://www.CorePsychBlog.com Dr Charles Parker

      Angi,
      Excellent question – and that, as they say, is exactly the point. Not at all like Strattera [see the revised comments at the end of this Intuniv post, & not an SSRI. Method of action is completely different in that it does not modify serotonin, dopamine, or norepinephrine, the big three. Rather, it facilitates/improves the activity of the glutamate networks through the alpha2a post synaptic receptor. Different action entirely – different than any other ADHD medication.

      Having said that, Intuniv isn’t for everyone. If your daughter has a reaction to Intuniv she likely is already over the top of the window on glutamate, and her ADHD is caused by imbalance either with that glutamate abundance, or a deficiency of another neurotransmitter, such as PEA. See the NeuroScience page here at CorePsych Blog for more details.

      Please keep us posted on her response to Intuniv if you and your medical team try it.
      cp

  • Mary Chapman

    Hello Dr. Parker,

    Gina Pera sent me the link to this e-conversation and I’d like to chime in. My 12 yr old daughter was diagnosed with ADHD 4 years ago at the Amen Clinic. She was identified as the “Ring of Fire” subtype, with oppositionality, inattentiveness, and restlessness. She was prescribed Tenex (guanfacine) and Omega 3 oil supplements.

    The results are nothing short of amazing. She only takes 1 mg of the guanfacine each morning and evening and she is no longer oppositional, there is little fight picking behavior, and she went from needing a reading tutor to performing above standard at school. As the Amen Clinic only served as the referring clinic for the diagnosis, I have met and spoken with over 10 different doctors in general pediatric practice and NONE were aware that Tenex is a medication to treat her type of ADHD. In fact, the Amen Clinic said that on stimulants, her aggressive, defiant behaviors would be magnified, not helped. Please continue to inform your colleagues and patients about the benefits of Tenex. For our family, it has been fantastic.

    Sincerely, Mary in Seattle

    • http://www.CorePsychBlog.com Dr Charles Parker

      Mary,
      Thanks for the input, look forward to commenting more this PM. As a quick comment: I have seen SPECT brain imaging evidence frequently provide new, useful information, and glad to hear it worked for you. Love the Amen Clinic team up there in Tacoma, had a great time with them on a visit in about 2003 during a speaking tour up there.

      See ya later,
      cp

    • Denise

      Mary,

      Isn’t Intuniv the same as Tenex…both guanfacine? Just that Intuniv is slow release? I am very new to the world of Meds, but that’s what I’ve gathered. I have looked at Amen’s subtypes and the most accurate for my son would be Ring of Fire as well.

      Thanks,

      Denise

      • Denise

        Got so immersed in the comments, forgot to re-read the article above. I just answered my own question, or Dr.Parker did ;)

      • http://www.CorePsychBlog.com Dr Charles Parker

        Denise,
        Glad you looked it over and found the answer… it is the same drug, but studies and my clinical experience thus far is that it is an improvement, and a different medication in effectiveness. Post coming soon. I have recorded several short Intuniv Cinchcasts over here, – the last one on dosing is pretty straightforward with specific info.
        cp

  • Denise

    Dear Dr.Parker,

    I stumbled on to your website while researching Intuniv. My son just started Intuniv (1mg the first week, and 2mg since) We are on 2 weeks and 4 days now. Because of his weight, the Dr. would like to keep him on 2mg. I don’t see any marked differnce other than he is tired, eyes a little puffy, and grouchier than usual, I think because he is so tired) He sounds very much like Kate’s son. He had been in a private school 1st through 3rd, but was expelled in 3rd grade due to his ADHD. He is extremely bright as well. But what you wrote Dr. Parker “…the oppositional, irritated, frustrated child with ADHD…” also describes my son. This is his first med, we’ve tried 6 months of neurofeedback, the bio-medical approach, a naturopath, and he’s been gluten free for 3 years, no processed foods or dyes, all in an effort to avoid meds, but all to no avail. Intuniv seemed like the best med for me, his Mom, due to it’s gentleness, lack of major side affects, and that it wasn’t a stimulant. I was hoping to see better results by now with the Intuniv because all the lit says that you should see results within 2 weeks. I did have his neurotransmitters checked when we were trying the bio-medical approach. If I remember correctly, his seratonin was low and his glutamate was high. Dr. Parker you mentioned some times neurotransmitters can affect how the Intuniv works. Would appreciate your comments as well, and thank you for your web site.

    Denise

    • Denise

      Correction: Diagnosis was ADHD/hyeractive inattentive

    • http://www.CorePsychBlog.com Dr Charles Parker

      Denise,
      Stay tuned, I will write a comprehensive reply tomorrow, including answers to all of your questions and much more. Intuniv does require some different thinking, and be prepared it will be a longer than usual post. – And I will clarify what I have seen with neurotransmitter biomarker measurements in my office in one case with an adverse event. The challenge, we are, as I pointed out here, beyond simple synaptic thinking, opening the big door of ‘brain networks’ and glutamate neurotransmitter activity.

      And BTW, makes no difference about the superficial ‘appearance’ diagnosis: The pharmacology is often the same for D or HD… I regularly use the phrase ‘ADHD’ as the entire field is shortening that label to include both D and HD subsets. Many see little point in differentiating decreased executive function – either acting or thinking.
      cp

      • Denise

        Thank you Dr.Parker! I look forward to your reply. I hope that my sons neurotransmitter levels will not induce an adverse reponse!

        Regards,

        Denise

    • http://www.ADHDRollerCoaster.com Gina Pera

      Hi Denise.

      Obviously, I’m not Dr. Parker. ;-)

      Just curious, though…is there some specific reason you don’t want your son to try stimulants? Or have you heard too many scare stories?

      Gina

      • Denise

        I always felt like meds were just masking the problem, but not “fixing” anything physiologically. I just felt like meds were a band-aid. But I knew at some point, I needed to be open minded enough to meds if he was not improving or having “successes” in his life. After 2 years of actively pursuing a purely holistic approach, he wasn”t where he needed to be, and I felt like he was stalling. So we pursued meds. I did hear horror stories about stimulant meds, weight loss, inability to sleep, depression, etc…etc… I was very pleased when the Dr. we were referred to recommened a med like Intuniv.

        • http://www.CorePsychBlog.com Dr Charles Parker

          Denise,
          Thanks, missed my assumption a bit, but guessed that the long wait without meds did have a substantial, thoughtful consideration. So much of what we do with the ADHD label is predicated upon the limitations placed on the diagnostic categories which have evolved from those aforementioned appearances.

          Your doc was right, Intuniv appears at this moment to be a very interesting non-stimulant alternative. More tomorrow,
          See ya then,
          cp

      • http://www.CorePsychBlog.com Dr Charles Parker

        Gina and Cathy –
        I made the assumption that Cathy had a problem with stimulants, as many do, because of the repeated bad press and misinformation about stimulant dosing and indications.

        And on a deeper note, if we are thinking about using marijuana for ADHD, as indicated in the recent NYT article it does appear that a large misinformation/practice hole exists out there that must be precisely addressed [hint ;-) ].

        Look forward to enlarging the conversation tomorrow.
        cp

  • http://www.ADHDRollerCoaster.com Gina Pera

    haha! That’s hilarious! Sounds like he takes after you — master of the bon mot!

    Yes, I would enjoy meeting you some day, Dr. P.!
    g

  • Josh

    Dr. Parker,

    How effective do you find guanfacine monotheraphy for ADD, with your patients?

    Thanks,
    Josh

    • http://www.CorePsychBlog.com Dr Charles Parker

      Josh,
      Some of my colleagues swear by their experience with guanfacine monotherapy, especially for Oppositional Defiance comorbid with ADHD. I have been using it more, but still primarily as adjunctive therapy, as I have so much confidence in the other combos such as stimulants and antidepressants. I can tell you with considerable certainty, from my own experience, that I have seen some few turn almost completely around with monotherapy on failure of all else. Perhaps it’s my population – when they come to see a psych, it’s been down a long road of treatment challenges.

      It does beg the question why didn’t I try it sooner. Simple answer, conservative philosophy, concern about side effects, which, upon systematic review, appear quite low – bringing it cautiously into the range of more regular augmentation and some first line therapy.

      The ODD/anger ADHD subset appears to be the direction the research has initially taken – with considerable positive results.

      Most especially you are asking about guanfacine immediate release – Intuniv is a whole different medication – and is clearly indicated for the attentional aspect as well.

      Have had some remarkable turnarounds with Intuniv in the short time it has been out.
      cp

      • http://adventurestudio.com Kate Scholl

        Dr. Parker -

        I have a 7 yr old son named Jack Henry who was diagnosed with ADHD, ODD and general anxiety at age 5. I recently was asked to remove him from a private school because of his impulsiveness and his refusal to finish his work. The final straw – he was told not to do something on recess and reacted by running away from school. After the teacher chased him down a busy street and asked him why he’d run away, he said he did not know why. He has taken Celexa for 1 year with good effects for the anxiety, but nothing for the ADHD or ODD. We then added Vyvanse which made him very sad and caused repeated vomiting even after careful titrating, so we took him off. Then we tried Strattera which made him extremely negative and did nothing for his moodiness and anger outbursts which, I should note, are always verbal and generally aimed at himself. He’ll scream at the top of his lungs that he should never have been born and that “nobody likes me” etc…. It seems to me that his perceptions of reality are always off and that he fails to connect his behavior with an outcome. It is either everyone else’s fault or he’s a “horrible person” because he accidently bumped into another kid. He has said to me many times that the mind he was born with is just “too much to deal with” and I believe him. He has great insight for such a young boy, but lacks self-control in spite of great efforts. In order to give you an idea of his thought process I’d like to share a quick story about a recent event. We were at the Dr’s office for a routine physical. He was sitting on the examining table and the Doc had it set in the highest position, which Jack did not like. He kept asking the Doc if he could get off the table. After about the 15th request, the Doc said “Jack, are you afraid of heights?” and Jack said, “No, it’s gravity I have a problem with.” He seems to have knowledge beyond his age, and yet it has been a struggle to teach him to read because the process of learning is terribly boring to him.
        Previous to taking the Celexa, he briefly took Metadate cd but his anxiety was off the charts so that’s when we decided to just go with the SSRI. Of course this did nothing for the ADHD focus and impulse problems so that’s when we started trying different meds. Now we are back to taking 10mg of Metadate each morning and have added Clonidine .5 mg at night in the hope of evening out his moods. His Dr.offered to prescribe intuiv, but said it was the same thing as Clonidine with a slightly different delivery system. In addition to the medication, Jack works with a child behavioral therapist who is great with him. We will continue to see her on a weekly basis. It has been about 10 days since we started the the new meds and I have seen a little improvement, but he is quite tired from the clonidine which I’ve been told is normal can take 4-8 weeks to take full effect and get over the tiredness. The other option the Dr. offered was risperidal which may be the next step if this does not work. Jack is currently doing his school work at home until the end of the semester. He will start at a new school next semester which is a Montessori based private school. He is very bright and very creative and the Montessori system seems like a better fit for his personality (I hope). My husband is very much against putting him in our public school system with a special ed “label” because he is so bright. I’m not sure where he fits, but I do know that if we could find the right medications, he will eventually discover what a truly wonderful mind his is. I would love and appreciate your comments. Sincerely, Kate

        • http://www.CorePsychBlog.com Dr Charles Parker

          Kate,
          Increasingly we are seeing delightful, smart kids like Jack who come up completely refractory to both families of stimulant meds, and it is a heartbreaker… but the good news is – there are more paths to trod.

          On a macro level, I do disagree with your doc. I fully admit that I had the same reaction as he did about Intuniv, but from my the research and some limited experience in my office, it really is a different drug. Yes, I speak for Shire, have been to all the Intuniv training, but that doesn’t make me unaccountable to you or my patients. The interesting thing about Intuniv is the mechanism of action and the half life.

          The mechanism of action is the same as Tenex, not Clonidine, it hits the alpha 2a receptor not 2b and 2c, making it less hypotensive and less soporific, less sedating by far. In research, in a forced dose titration, pushing the dose to see the safety parameters for FDA review/hopefully approval, they showed only 6% as compared to placebo 4% hypotensive reaction in a study with over 500 6-17 yr olds. Sedation was the biggest side effect, but I use sedation as an indication to find the top of the window for proper dosing. I will be writing a blog on Intuniv soon, as folks do need more info. Bottom line he sounds like a perfect child to give Intuniv a try.

          My colleagues who have done the research had the same take as your doc, even knowing it wasn’t like Clonidine per se, and have been uniformly surprised at the excellent response with kids just like Jack – in fact Jack is their main focus – the oppositional, irritated, frustrated child with ADHD. Titration strategy is with the package, completely simple – here is an audio cinchcast I did on Intuniv [summary of NYC Satellite Meeting], and another on dosing is on the way, somewhere in the ethers apparently, at this moment.

          Beyond the meds, if that doesn’t work, I would look very carefully at immune dysfunction, bowel challenges and is-he-a-picky-eater? status. If he doesn’t fit one or all of those, I will be surprised. If he doesn’t the very next intervention, mandatory in my opinion – having had so much good response to neurotransmitter testing – is a complete NeuroScience Lab workup. Yes we can do it, but perhaps you can find someone in your town who can read and recommend locally at that link on their website.

          Many more options, and you don’t have to just do one. I would try Intuniv, it’s an easy, safe start, and do the rest anyway. If we can see what’s going on with his brain, why not?
          cp

          • http://adventurestudio.com Kate Scholl

            Dr. Parker -
            I appreciate your quick response to my comments regarding my son. I will take your advice and ask his doc to prescribe Intuniv. Is there a problem with abruptly switching from Clonidine to Intuniv? In response to your other question, Jack is a very picky eater and is easily “grossed” out by the look and texture of certain foods. In terms of his immune system, he tends to catch every virus that comes along.

            I am very open to Neurotransmitter testing. I live in Omaha,NE and wonder if I could have it done here at the NE Med Center or another medical facility. I have good friends in Richmond, VA and since I visit them periodically, I could coordinate an evaluation and testing of Jack at your offices.

            Thank you again for your feedback.

            Kate

            • http://www.CorePsychBlog.com Dr Charles Parker

              Kate,
              Look forward to talking, yes we can connect by phone, and regrettably don’t know anyone out there close to this kind of comprehensive intervention strategy.

              One additional point for any readers starting Intuniv with a similar child: Go low and slow, even more low and slow than the package insert recommends [maybe he will nly need 1 mg in the AM?], and don’t be disappointed if he can’t take Intuniv at all and has an ‘unpredictable’ angry reaction. I do think Intuniv very well might work, but with immune dysregulation so likely, the entire sweep of easily measurable Neurotransmitters can be markedly off balance, – and these are the very people that appear to have a reaction to Intuniv. I only had one bad reaction to Intuniv so far, and the NT testing showed exactly what I am telling you.

              The good news: we’re getting your guy on track one way or another!
              cp

            • http://www.ADHDRollerCoaster.com Gina Pera

              Hi Kate,

              It’s the rare physician who is so generous with information at a website or blog. Dr. Parker has helped many people who were failed by other physicians.

              I had to laugh at your son’s comment about gravity. My husband, did, too. He said it sounded like something he would have said as a 7-year-old.

              Hang in there and best of luck,

              Gina

            • http://www.CorePsychBlog.com Dr Charles Parker

              Gina,
              My grandson had a great comment the other day that bears repeating: In the process of changing his diaper, my verbally adept daughter-in-law commented on his anatomy, saying “Yes, that is your penis.” As an old soul with great timing – in an infants body – he replied [will be 2 in Jan] “Boys have penises…. and…..girls have cell phones.”

              I am so pleased to share these times with mavens like you, Gina. You too are an old soul with timeless wisdom, – I do look forward to chatting over coffee with you one day, and do appreciate your kind remarks.
              cp

  • http://www.ADHDRollerCoaster.com Gina Pera

    Thanks for the translation, Dr. Parker. Always welcome!
    Gina

    • http://www.CorePsychBlog.com Dr Charles Parker

      Thanks Gina!
      I have two presentations this week just helping our medical family with the research and the neurophysiology – new receptors, some new neurotransmitters, and different objectives in some respects. These are not ‘product oriented’ but more neurophysiology, information to help how to understand the new mechanisms of action. Very interesting stuff!
      cp

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